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ELECTRICAL.!NSPECTOR RECORD <br />APPROVALS DATE ID/S!G.COMMENTS ()WNER IIUILDF]R I)I]I,CARAl'ION <br />I hcrchy affirm undcr pcnnlty of perjury thal I am excn)pt fronr lhc (irilrrchrs' Licelsc Law for thc {i)llowing rcrson (Sec.7o]l.5 <br />Busincss dnd Profcssion Co(lc): Any City or Counly lvhich rcqnircs il ftrnlit lo conslnrct. sllcr. improve. dcrrtrlist or repair lny <br />slruclurc. prior lo its issuancc. also rcquircs Ihc applicilnl lbr such;rcrnrit lo lilc n sigDcd strtctrrcnt thal he or shc i\ liccilscd ptrrsutnt <br />lo thc prolisioils of lhc Coillra.krt s Liccnsed l-rw (Chnllcr 9. Comnrcncing s'ith Scclion T(XX) of Division .3 ol thc Bu\incss:.nd <br />Profcssions Codc) oI lhnl he or (hc is cxcnlpl lhcrcfronr and thc hasis lirr thc allcgcd cxcnrlilion. Any violaliur of Scctkrn 7{)3 1.5 hy any <br />rpplicant for r pcrmil suhjccls lhc apllicilnt k) a civil pcnnlly ol' nol Dxrrc lhan llvc hundrcd dollilrs {S5(X)). <br />-1. <br />ds owncr of lhe pfi)peily. oilny cnU,kryccs with wagcs as thcir solc compensalion. will do lhc work and thc struclure is n(,1 <br />intcndcd orollcrcdlirrule(Se.7{X4.BusirtcssandProfcssiotrsCodc:ThcConlr{cbr'sl,iccnsehwdocsnotapflytoino$ncrol' <br />thepnrfrcrty whobuild\orimprovcsthcr@n.andwhodocssuchworkhinlsclforhc'rsclforthroughhisorhcrowncntpk)yecs. <br />providcdlhatsuch itrrprorenrnlsarcDoliiendcdoroJlcrcdfor{lc.ll.ho$'evcr.lhchuildiigorimprorenEnlissoklrvilhinoncvear <br />ofcoiDhttnl. lhc Owncr Buiklcr will ha\c lhc hurdcn of proving thil hc or \hc did not huild or improvc the protEny for thc purF)$ ol <br />salc). <br />_1. rs o*rcr of lhc l)ropcrty. rnr cxchsi!cly contractitrg s ilh liccnscd conlract)r\ l() con\lrucl lhc proiccl (Scc- 7(!14. Busincs\ <br />nnd [\rrfissi<t Codc: 'l hc Contrnctor's l-iccnse l,rw docs not tpply h iln owncr ol prol)crly who huilds or inrprovcs thcrcon. <br />and Nho conlrocls li)r such projccls wilh a Con(raclor(\) liccnscd pur\uant lo lhc Coiltraclor's l-iccnsc l-au ). <br />-lltrlcxetr]nlunderscction-.B'&P,C.forthisrcason'l)atr Orner: <br />IVORKtiRS', COI\IPllNSA',il0N <br />I)I'CI ARAI'ION <br />I hcrcby aflirnr under pcnalty of pcrjury onc oIlhc following declaralions <br />_l have ruxl will mairilain a Ccrlilrcalc of Conscnt to Sclllnsurc for workcrs compcnsation. as Fovidcd for by Scction 37U) of thc <br />l:txrr Codc. f<rr thc pcrformancc ofthc work for which thc pcrmit is issucd. <br />I hrvc rnd will nraiDtlin workcrs' coilrlrcnsalion insurrncc. {\ rcquircd by Sccttrn 37(X) oflhc Lahor Codc. lor thc pcrlirnuncc ol' <br />lhc work for is issucd. My workcrs' conlpcnsdti()n insurance cdfticr and Jx)licy nunthcr ilrc: <br />T naf. <br />I I - <br />"-t^lq <br />Policy <br />_l ccrlify Ihrl in lhc pcrfornrancc of thc work l'or which lhis pcrtrlit is issucd. I shall n()l empk)y any pcrson in any nlanncr <br />sorsk)bccoilrcsubjccttothcworkers'c(nlpcn\iltionlnwsofCillilbrnia.andngrccthntiflshouldhcconrcsuhjccttrthc <br />sorkcrs'coillpcrlsillionlrovi\ionsofScction-t7{X)oflhcl-at{)r(ixlc.lshall.fonhwilhconlply$ilhrho$pfi)visi(rns.. <br />IVARNING: l:ailurc k) sccurc workers'compcnsntion colcragc is unla\vltl. aild shall suhirl r[ crnpk)ycr to oirninal frnilllies and <br />civil llncs uf lo onc hundrcd lhousan(l dollrrs ($IU).(XX)), in r(ldilioil lo thc cosl of compcnsrtion. dnitges as providcd for thc <br />Scclion 1076 ol thc Latxrr Codc. inlcrcsl and alktrncy s ltcs.(-tr-tl Appliunt:fl)ale: - <br />DECLARATION <br />Ihcrchyatlirnrundcrpcnaltyoffcrjurythatlanrliccnscdundcrpr<)visionofClhaplcr9(cotr!mencingwithScclionT(XX);ofDiviskrn3 <br />of thc Busincss and Prolcssions Code. rnd my licensc is in full lorcc xild ctfccl. <br />Liccnsc ,iccn\c <br />l)ote:'Contraclor: t(#"r*(- <br />CONSTRUCTION LENITING ACF'NCY <br />I herchy affirm under lEnshy of pcrjury lhal thcrc is a construction hndirg agcncy for the pcrlormancc of thc work tor u hich this Jrrrnit is <br />issued (Sec. -i097. Civ. C.). <br />kndcr's Nanrc: <br />l-crrlcr's Adtlrcss: <br />APPLICANT DECLARATION <br />I hcrcby allirri undcr penalty ol pcrjury onc of the lblbwiig dcclnrations: <br />DenDlilbn Pcrmits-Ashcstos Nolificalion Fedcral Regulalions ( Iitlc 40. Pan6) <br />_Rcquired Lcttcr of Notilicillion <br />_l ccrtily lhilt Ihc fcdcral rcgulations rcguding asbestrs rernovnl Arc nol rpplicrblc t) lhis projccl. <br />(f t ""nify rnor I havc rcad this application and sralc thal thc ahovc inlbrnmtion is conccl. I ngre to comply <br />ordiiiinccs and Strlc Laws rclaling to buikling conslrucli()n, md hcrcbyaulhorizc rcprcsenhlivcs ofthis City <br />ahovc nEntioncd propcny lbr inslcclion purfnscs. <br />wilh all ('ity an(l ('()rnty <br />ilnd Counly lo cntcr upon thc <br />Appliutrl or Agcnl Sigtrtrturel <br />l'cmritre narre{print): * <br />Y(t:E <br />San,l ( , n <br />I)alc:2 <br />Site-Work <br />Underqround <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bondinq / Groundinq / UFER <br />Transformers <br />Torqueino <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouoh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinos (T-Bar Rouqh) <br />Meter Release <br />Rouqh <br />Service Jt/eter <br />FINAL <br />Notes, Remarks, Etc. <br />+