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ELECTRICAL.INSPECTOR RECORD a <br />owNt:R ltUil,DuR <br />I hocby affm undr peralty of psjury that I m exempt frorn lhe Contractors' License Law for the following rcson (Str.7031.5 <br />Businss ed Profcsion Code): Any Cily or County which require a;rcmit to con9ruct, altc, improve. donolish or rcpair my <br />stntcture. prior to its issudce. also requirB lhc applicant for such pmnit to file a si8ned slatemtrt that he or she is liceoscd pu6udl <br />to thc provisions of rhe Contractor's Licensed law (Chaptn 9, Comencing lvith Sstion 7000 of Division 3 of the Busins ild <br />ProfessioosCode)orthatheorshcisexemptthqefrommdthebdisfortheallegedcxonption. AnyviolationofsetionT0ll.5byany <br />applicant for a pmit subjats the applicant to a civil penalty of nol more thm five hundred dollas ($500). <br />_1, o orvnq of the prop€rty, or my employG with wag6 6 their sle comperoalion. uill do the wort and thc strucluf is mt <br />intmded orotTsedforsle(56.T044.BusinesudProfssionsCode:TheConlractor'sLiccnseLarvdoenotapplytomownoof <br />the pmpcrty who builds or imprcv6 thq@n. ild who do6 such rvork himself or hmelf or thrcugh his or hs out mploye6, <br />provided that such imprcvmots ue not intoded oroffqed for sle. If. howwfr. the building or irnprovcmot is mld within one yw <br />ofcomplaion thc O*nq Builds will harr the budo ofproving tha he or she did not build or irnprove the propqty for the purpo* of <br />sale). <br />_1. 6 ownq of the ;ropoty. m exclusivcly contracting with licmsed contractos to comtrud the prcject (Sec. 7044. Businru <br />md PofssionCodc:'l'heContractor'sLicenseLawdo6nolapplytodown6ofpropeny$'hobuildsorimproveslhs@n. <br />and who contBcts for such proims with a Contraclo(s) licmsed puEuant to the Contractor's Licme l,aw)- <br />Dtte:_ Owner:_ <br />gQ8KE8$]CAUPIN.SAI]Q! <br />DECLARATION <br />I hereby allirm undr poalty ofpojury one ofthc following dcclaratiom: <br />_l have md will maintain a Ce(ificate of CoBot to Self-lnsure for workers' conrpensalion, o providcd for by Section 3700 of thc <br />Labor Code. for the pqfonnace ofthe work for which lhe p6mit is issucd. <br />_l have and will maintaio workers' compeNation iNurance. u required by Srtioo -1700 of the tabor Code. for thc psfonnocc of <br />the sork for which this pffnit is issued. My workers compmsalion imurance canier md policy numbo ue: <br />I m excmDt undff Strtion-, B. & P.C. for this reaon. <br />Policy Numbq: Expire: <br />-- <br />Lender's Ad&e: <br />ficaity ttatin thc pqformance of the work for which this pmit is issued. I shall nol qnploy any pcon in my mmnr <br />$ 6tobe{omesubjecttotheworkqs'comp$ationlawsofCalifomia.mdagreethatiflshouldb€comesubj(ttothe <br />workm' compaetion provisiom of Scctioo 3700 of the tabor Codc. I shall. forthu'ith comply wilh thos provisioN.. <br />WARNTNC: Failure to wwe works'compqsation coloage is unlarvful, and shall subject m onployer to dminal petrahie md <br />civil fines up to one hundred thoused dollils ($100.0001 <br />Seclion 3076 of the tnbor Code, inlerGt md anomey s f6. <br />). in addition to thc cosl of a provided lor the <br />I horby aflinn under poahy ofpojury that I an licmsei of (commmcing with Sstion 7000) of t)ivision l <br />of the Busin* md Prcfeiom Code, ard my licmc is in full force ed eff6t. <br />Nunrlrer:J <br />Liccnse <br />CONS'I'RUCTION LENDINC AGENCY <br />I heeby affim undo ;rtrahy o f psjury that th6e is a comtruction lending agency for the pofomance of the work for which this pornil is <br />issued (Sec. 3097, Civ. C.). <br />Lender's Name <br />A?PI,ICANT DECLARA'I'ION <br />I h6dry aflim unds pmalty ofperjuy onc ofthe follorving declaationsr <br />Demolilion P€mits-Asb€tos Notification Fcdral Rcgulations (Tille 40. Part6) <br />-Rquirerl <br />Lctld of Notification <br />-l <br />cqtiry that thc fedad reSulatioc regading abcstos ronoval oe not applicable lo lhis prcjd. <br />_l cdify thd I have red this application ild state lhal the above infomation is corst. I agrE lo comply *ith all City and County <br />ordinancB md State Laws relating to building construction. ild htrcby authorizc repramtativG ofthis City md County to mta upon the <br />above molioned prcpcrty for impetion <br />Applicailt or Agcilt <br />DATE ID/SIG COMMENTSAPPROVALS <br />Site-Work <br />Underground <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 />Buildinq <br />Under Slab / Floor <br />Bonding / Grounding / 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 />Ceilings (Hard & Soffit Rough <br />Ceilinqs (T-Bar Rouqh) <br />Meter Release <br />Rouqh <br />Service Meter <br />/a-29 -fi , 2,,/oFINAL <br />Etc.Notes Rema <br />Permite name (print): <br />l)nle: <br />n*., l-/q,, /, /,', -'/ ' I <br />orrc: ly' /, ,. /, /,coot,"to", f f <(€fl/Oed{,-r-/ '7 <br />tl,ta "t rl[ -