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ELECTRICAL.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I heeby affirm unds penaly of perjury that I m crempt fiom the ConlradoB Licmse law for the follorving rcNn (5(.7031.5 <br />Businas and Prof*ion Code): Any City or County rvhich requira a pmit lo construcl. aha. improve. dmolish or repair any <br />structure. prior to its issumce. also requirB the applicmt for such pennit to file a signcd statemmt lhal he or shc is licmsed puBuml <br />to thc provisions ofthe Contraclor's Liccnsed Larv (Chapts 9. (-orrnencing rvith Scction 7000 ofDivision 3 ofthe Business and <br />Pofe$ions Code) or (hat he or she is exempt thqefrom md the bmis for the allegcd ermption. Any violation of Selion 7011.5 by any <br />applicantforapmnitsubjststhe applicanttoacivilpenallyofnotmorcthanfivehundreddollas($500). <br />I. ru ownr oflhe pro[E(y. or my employs rvith wage o their sole compensation. will do therwork md the5truorc is not <br />intmded oroffoedforule(Sa.7044.BusinosadProfesions(--ode:-[heConlraclor'sLicmseLawdo6f,otapplytoanoMsof <br />the prepoly who builds or improvs lh6mn. dd who do6 such wo* himselfor hoselfor through his or he om employces. <br />provided thal such imprcvmmls ae not intmded or offqed for slc. ll. horvo'a. the building or inpmvernmt is sld within one )@ <br />of complelion. the (hns Builds will havc lhe budm of Fro\.ing thal he or she did not build or imprc\'e lhc trcpqty for the purpos of <br />sle). <br />- I. as orvner oflhc property, iln exclusively contractirrg with licensed corlractors to conslruct the preject (Sec. 7044. Uusins <br />and hofsionCoder'lheContractor'sLicensel,awdo6notapplyloanownerofproperlyrvhobuildsorirnprovesthereon. <br />and rtho contracls for such projsls wilh a Connaclorls) licosed pursuant 10 lhe Conlractor's Licmse Larv). <br />-l <br />m exempt unde Setion-B. & P.('. for this reaon. <br />Dsle:_ Owner: <br />\\ ()liKllltS' ( Ol\ll'liNS;\'l lON <br />DU( t,,\r{,\ I ION <br />Iirlkrrr irrB dcchrations:I hereby allim undo one oflhe <br />I have nraintainaCenificatcofConscnltoSelf-lnsureforworkss compmsalion,as provtledforbySetion3T00ofthe <br />Lalxx the pslonnance oflhe rvork for rvhich the pmnit is issued. <br />by Strtion -3700 of the kbor Code. for the pqfommce of <br />lhe insurmce canio md lnlicy number ae: <br />tblicy <br />I of this is issued. I shall any ptrson in any mann6 <br />so 6tol <br />workss' <br />to the workd's'compensalion larvs ofCalifomia. and agree that ifl should becoDle subjtrl lo lhc <br />provisions ofSeclion 3700 ol the Labor Codc, I shall. forthrvith cornply rvilh those provisions <br />WARNING: Failurc to sue $ork6'comp@sation covmge is unlarvful. sd shall subjst an mployo to oiminal pmaltia and <br />civil lins up to one hun&ed thousmd dollas ($100.000). in addition lo lh€ cosl of compeNation. dmagm m provided for the <br />Sstion -1076 oflhe l-abor Code. intscst and attomey's fe€s. <br />>o <br />I,I('I]NSED ('O NTR CTOIt <br />DEClr'\RA I'ION <br />I hcreby affirm unda penalty of periury that I an licensetl undr provision ofChaptq 9 (commmcing rvith Section 7000) of Division 3 <br />of the Busines and Professions Code. md my licmse is in full force md effect <br />Liccree Cls: 4 10 <br />r)nrc: O lf Of lZolo (,onrrrcror: (-,O: <br />CONSTRUCTTON I.ENDTNG AGENCY <br />I haeby affrm unda lmalty of pefjury that th6e is a comtruoion lendin8 agmcy for thc pqfonnacc of the rvork for which this p6mit is <br />issucd (Se. 3097. Civ. C.). <br />tmds's Addrs: <br />APPLICANT DECLARATION <br />I hecby affm undo penalty ofpsjury one ofthe following dtrlarations: <br />Dernoliiion Pmils-Asbstos Notification Feddal Regulations (Title 40. Pd6) <br />-__Requbed Ldt6 of Notifi@tion <br />tst "erriry <br />tnar rfr" fuoal regulations regdding 6b6los rqnoval are not applicable to this prcject. <br />I ccrtify thal I havc reod this applicalion md stale that lhe abovc infomalion is corect. I a8re to comply with all City and County <br />ordinance md State krvs relating to building coNtruction. ard hecby authorize repreolativ6 of lhis Cily md County to flt6 upon the <br />above molioned propcny for inspedion purpos6. <br />,lpplicnil( or Agcilt Signrturcl <br />Pernits nxne (print): <br />;i -z--'narc, 6/ /og/zo-o <br />Site-Work <br />Underqround <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bondinq / Groundinq / UFER <br />Transformers <br />Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilings (T-Bar Rough) <br />Meter Release <br />Rough <br />Service Meter <br />FINAL 5-1$-Ll)Z-Lr s,Jr:./P\ 2D <br />Notes, Remarks, Etc. <br />L <br />LicenscNumber: 91 Ll5+ <br />Lef,dcr's Nane: