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ELECTRICAL.INSPECTOR RECORD <br />Rev.08-07-2015 <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hqeby 8ffirm undtr penalty of psjury that I m exempt from lhe ContractoE' Licme law for lhe following r@n (Src.7031.5 1 <br />Busincs ad Profsion Codc): Any City or County which requira a pcnnit to comtrucl. alla. improve dmolish or rcpair my <br />structuc, prior lo its isuoce. also requirGlhe applicel for such p€rmil to file a signed statmot lhat h€ or she is licmed pmuilt <br />to the provisioN of lhe Contractor's Licensed Law (Chaptq 9, Commcncing with Setion 7000 of Division 3 of thc BsinN a{d <br />ProfcsionsCode)orthatheorsheisexcmptthoefromddthebasisforthcallcgedexmption. AnyviolationofsslionT03l.5byany <br />applicant for a pmit subjsts the applicant to a civil penalty of not morc lhu ,ivc hundred dollus ($500). <br />I, o owno of the prc[Erty, or my crnployffi with wag6 6 their sole composation, will do the work dd the structue is not <br />intqdqi oroffqcdforsale(Sc.T044,BusinessmdProfmionsCode: TheContractor'sLicmseLawdocsnolapplytomown6o[ <br />thepopoty whobuildsorirnprovethd@n,ildwhodo6suchworkhimsclforhoselforthroughhisorheownemployec. <br />provided that such improvonols ae nol intoded or offqed for sle. If. howcvq. the building or imgovment is sld within one y@ <br />ofcomplction, the Osrm Builda will have the htrdo ofproving thal hc or shc did not build or tnprovc lhe propqty for the purpo* of <br />gle). <br />_1. roma of the prcpsty, m exclNively contracting with licGd contractoG to coNtruct the froj€t (Se. 7044, B6ins <br />od Ptoftssion Code: The Contractor's Licmsc Law do6 not apply lo e owns ofpropqty who builds or improvB th6sn. <br />and who contmds for such prcjets with a Contmcto(s) licmed puE@t to the Contractor's Lic6e L{w). <br />I an exenlpt under S{tion-, B. & P.C. for lhis redon. <br />DECI.ARATTON <br />I hoeby alfim unda pmalty of pojury ooe of thc following dclilatioN: <br />_l havc ud will mintain a Cenificatc of CoMt to Selflsure for workc' compcnsalion, c provided for by Setion 3700 of thc <br />tabor C6dc, for the psfot]@ce of the work for which the p6mit is issucd. <br />{ havc and will maintain workm' compcnsation iruudcc, a requircd by Setion 3700 of the Labor Code, for the psfommce of <br />lhc perrnit is issual. My insurance carier md policy number oc:L <br />Policy Nunrbe:(- t z( <br />_l cefliry that in thc psformance of thc work for which this pemit is issued, I shall not mploy any pmon in ay mmner <br />s 6 to b€come subjet to thc work6' comp€nsation laws of Califomia. ild agre thd if I should beome subjct to the <br />workm'comp€nsationprovisiomofSection3T00oftheLaborCode,lshall,fonhwithcomplywilhthosprovisiorc.. <br />WARNING: l.-ailure to scure workcrs'conrpcnsation coverage is unlawful. and shall subjcct an qnploycr to siminal penaltiB and <br />civil fines up to one hundred thouwd dollus ($100.000), in addition to the cost of compemation,u provided for the <br />Section ]076 oflhe [-]bor CoJe. <br />,,,",1/z// z o <br />intersl md attomey's fe6. <br />T t <br />DE('LARA I'I()N <br />I h6eby amrm und6 penalty of p€rjury that I an licensed undo provision of Chaplo 9 (comocing with Scction 7000) olDivision -1 <br />of the Busins md Profesiore Code, ud my licme is in full force ad effect. <br />l-iccnsc -c(c Nrunlxr:rozqc( c( <br />ZU ('onlreclor: <br />W <br />I hrcby alfirm undr penalty of psjury lhat lhqc is a coctruclion ldding agocy for the pofomece of thc work lor which this pqmit is <br />issucd (Se. 3097, Civ. C.). <br />Lender's Nanle: <br />l-ender's Addr6s: <br />APPLICANT DECLARATION <br />I hotbyaffim undq psralty ofperjury onc ofthe following deldations: <br />Demolition Pqmits-Asb6tos Notification Fcdoal Regulations (Titlc 40, Part6) <br />Requircd Lcntr of Notifi cation <br />_l cqtify lhat the fedsal re8ulations regilding cbctos rmoval are not applicable to this prcjet. <br />-l <br />ccrtify lhat I have rad this application with all City and County <br />ed Couty to ot6 upon theordinancG md Slale laws relating to <br />above molioned property for <br />Applicant or Agmt <br />Permile nanre C (cro,0 i?-, <br />z/-@ <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor A <br />Bondins/Crffin-q/UFER bq;rc l/-{--o I <br />Transformelr- -Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilings (Hard & Soffit Rough <br />Ceilinqs (T-Bar Rouqh) <br />lt/eter Release <br />Rouqh lt hi 44 <br />Service [t/eter ID.YIF W ti,-/u,lrL <br />FINAL to - n.?h -l?c-tq ilc69 v?:) <br />Notes, Remarks, Etc.