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ELECTR!CAL-INSPECTOR RECORD <br />Bev.08-07-2015 <br />APPROVALS DATE ID/SIG.COMMENTS OWNTiR BUII,DI.]R DI),CARATION <br />IlErcbyaffirnrundcrp.traltyofperjrrryth0tIilDcxenrptfroDthcC'onractos LiccnsclawforthcfollowingEasn(Sec.70]1.5 <br />Busincss and Pro,tssion Codc): Any Cily or County which rcquircs a prmit to conslrucl, altcr. improvc. dcmlish or rupair ay <br />structurc. Fi(,r () its issuance. also rcquircs the applicail for such lEmlit to filc a sitsned slatcrrenl that lE or shc is liccilsed pursusnl <br />to lhc previsions of thc Contractor's l,iccnscd llw (Chaptcr 9, Comrncncing with Scction 7000 of Division 3 of thc llusincss and <br />ProfessionsCode)orthatlEorsheiseren4rlthcrefionlardtlEbasisfortlEallesederenrplioo- AnyviolatiorofSectionT03l.5byany <br />applicilntforapennitsubjeclslhe ipplicantloacivilpemltyofnotrrerethunfivehundrcddolltrs($5LU). <br />_1. a\ owncr ol'thc foJrcny. or my crnployces with wagcs as their mlc mmpcnsation. willdo the work ard lhe stffim is mt <br />intculcr.l or offcrcd lor slc (Sa.7O1.1. Business and Prcfcssions Code: Thc Conlractor's Liccn* liw d@s not apply to m owncr of <br />the prulEny wlb builds or inproves tlBrsr! ud who does such work himself or herself or lkough his or her own enrployecs, <br />providcd that such impmvcrrcnts ec mt inlcftlcd or ofcrcd for eh. ll, howcvq, ttr boiHing or ifiprovcmnt is sld within orc ycu <br />of conrplclin\ lh Owrcr Buillcr will lmw thc buden ofpmving tlu lE or sh. did mt buill or irprcvc thc propcny for the pur[ps of <br />srle). <br />_1. as owrcr of thc propcny, lnl cxclusiycly contracting wilh liacnsed contracloN to conslruct thc prcjcct (Scc. 7(X4. Business <br />and hufbssiolCode:ThcContracbr'sLicenseLawdoesnotapplytoanownerofproFnywhobuildsorinrprovesthereo[ <br />and who contracts for such projccts wilh a C(rntrack)(s) liccnsd pursumt lo lhc Conrrctor's Liccnsc kw). <br />-l <br />anr exenrpl uDder Scctiotr , B. & P.C- tbr this reason. <br />l)ste:- <br />WORKERS' COITPENSATTON <br />DECLARATION <br />I hereby aflirm undcr pcnalty ofpcrjury onc oflhc li)llowing dccltuations: <br />_IhavesrdwillnuiilainaCenilicateofConsentloSelf-lDsureforworkers'conrpcnsation,as providcdforbySectionJT00oftlre <br />lnhor Codc, for the pcrfoflMnce o[ thc work lor which (hc pcrr[it i\ isrucd. <br />_llEveuMwillnuintailworkers'c(nDpetrsali(trri[sutance,as requiredbySecli(ill3700oflhehborCodc, <br />thc work lur which this trrnrit ir issuc.l. My workcrs' con{rcnsation insurdrcc cmicr ilxl ltulicy nunficr de: <br />,,,,,,, Ev€(6 €\ f <br />^i/lrr <br />ccsrnt4 | lzttgJ/q, <br />f()r lhe ltrli,rnuDce of <br />.4 ee c-o <br />t /2/tqc 3/Policy t---T---T <br />_l ccnily thal irr lhc ltrforDancc ol lhc work ftrr which this pcrmil is issucd, I shall nu enrploy any prson irr any mannc, <br />s as to bcconr subjcct to thc workcrs' cotrlpcnsation laws ol Calilomia. and agrcc thlt if I should bccorrc subjcct to thc <br />workers' co[lpensation prorisions of Section ]700 of thc Labor Cod€, t slull, fonhwith cornply with tho* prcvisioN.. <br />WARNING: Failure lo {curc workcrs'comlEnsalion covcrdgc is unlawful, and shall subjcct an cmployar lo oirninal pcnaltics and <br />civil lincsuploorchur)drcdtllrusanddollars($100,m0).iradditiortotlEcostofcompeNalion,danugcsuprovidcdforthc <br />allorrey's fccs., <br />DI'CI,ARATION <br />I hercby affrnr under lrnalty of pctjury that I anr licen*d undcr prcvision ofChaplcr 9 (conrrEncing wirh Scction ?UJO) ofDi!isiori 3 <br />of lhe tlusiness and Professions Codc. aftl mv license is in full forcc nrd cffcct. <br />License L Nu 2co7 b <br />LU <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby all'ifln undcr I^.-naky ol pcrjury that thcrc is a conslruclion lcnding agcncy for thc pcrlbrharcc of thc work lbr which this pcrmit is <br />issucd (Sec. 3097. Civ. C.). <br />[Jnder's Nanle: <br />[.nder's Addr.ss: <br />APPI,ICANT DECI,ARATION <br />I irrchy u.ftinr undcr l{nally of pcrjury onc of thc li,llowing dcclarations: <br />Dcnnlitk)n Pcrmits-Asbcst,s Notilicdti(rn Fcdcral Regulations (Titlc 40, Pmf, <br />_Rcquircd Lctrcr of Notification <br />_l ccnili that lhc li'dcralrcgulalir)ns .cgilding asbcstos rcrnoval nc not applicablc o rhis projcct. <br />stalc thal lhe ah)\'c inli)rnulior is corecl. I agre to conrply with ull City and Coutrty <br />uk)vc nEntioncd prcperty for inspecthn <br />ADplic&nt 0r Agenl <br />I'cmrilcc nsnrc <br />rcprcsntatives of thir City and k) cntcr rlx' <br />Site-Work <br />Underground <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safetv /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bondinq / Groundinq / UFER <br />Transformers <br />Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinqs (T-Bar Rouqh) <br />Meter Release <br />Rouqh <br />Service lVleter A\ <br />FINAL 6-[0-20 k.y4)$\ <br />Notes, Remarks, Etc.U