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ELECTRICAL-INSPECTOR R ECORD <br />APPROVALS DATE ID/SIG COMMENTS 0lvNIiR IIU Il.l)llR l)l.ll.('A RA'rl( )N <br />I hcrcby aflirm undcr 1Enalty of pcrjury that I m cxcmpt fmm lhc Conlmclom' Liens tiw for Ihc following rcason (Scc.703 1.5 <br />Busincss and Profcssion Code): Any City or County which rcquircs d [ErNil lo onslruct. alten impmvc. dcmlish or rcpair any <br />struclurc. prhr k, its issuancc. also requires thc applicant for such Jrnrrit to filc a signcd stutemnt lhal h. or shc is liccnsd pursuant <br />ro lhc lnrvisions of thc Contraclor's Licened hw (Chuptcr 9. Comtrcrcing with Scction ?fi)0 of Division 3 of thc Busincss and <br />Prcfcssions Codc) or thal hc or shc is crcmpt Ihcrcfrom and thc bnsis for lhc allegcd cxemplion. Any violalion of Scction 703 I .5 by .ny <br />rpplicant for s [Ermil $ubjccts tlE applicant to a civil pcntrlty of nol nmrc thon fivc hundrcd dollds (5500). <br />_1. as owncr of thc lrrlf,ny. or my emplo)es with wages .s thcir $lc Nmpcnsalion. sill do lhe work and lhc slfflw is mt <br />inlcmlq.l or offcrcd for sh (Sa.?O44. Business and hofcssions Codc: Thc Conlractor's Liccnsc lrw docs nol apply to an owncr of <br />lhcpnrlEny whobuildso.irprewstlr@n.andwhodessuchmrkhirnsclforherslforlhrcughhisorhcrownemployccs. <br />providc{t thdl such inrlrercmnts rc mt intendcd oroficrcd fo] suh. If. howcrcr,lhc huiHing or hrpmrcmnl is $H wilhin onc ]te <br />ofdnnphtkn,lhcOwrcrBuiHerwillharethcburdcnofpmvinglhalhcorshcdk notbuiHoritrprorcthcpmlEllyforthcpurlDsof <br />slc). <br />_1. as owncr ofthc p(rpcrty. am cxclu$ively contracting whh liccnscd controctors k, construct thc prcjcct (Scc. 7(N4. Busincss <br />and Pmlb$sionCodc:ThcConlractor'sLicenscLawdocsnolapplytounowncrofprolErtywhobuildsorimpmvcsthcrcon. <br />and who contracts for such prcjccts with a Grntmcto.(s) liccn$d pursuant lo lhc Conlroctor's Licens hw) <br />I ant excnnl un, <br />;",q llb <br />v <br />B.tirr lhis <br />I hcrcby affirm under pcnalty of pcrjury onc of thc following dcclarations: <br />_l have and will tnaintain a Ccrtificate of Conselrt to Self-lnsurc for workcrs' compensation. as provided for by Seclion 37fi) of thc <br />l:txlr Codc. for lhe performancc of thc work for which thc pcrmit is issued. <br />_l havc an6 will maintain workers'compensation insurancc. as required by Scclion 37fi) of the l-abor Code. for the [rcrformancc of <br />thc w<lrk for which this pcrmit is issucd. My workers' comlrcnsation insurancc calrier and plicy numbcr arc: <br />Policy Number: ExPires: <br />_l cerlil.v that irr thc pcrfornlancc of thc work lor which this pcrrnit is issuctl. I shall not ernploy any pcrson in any lllanncr <br />so lstobccorncsubjccttothcworkcrs'conrpcnsalionlawsofCalililrnia.artdagrccthatif'lshouldbcc<lmesubjccttolhc <br />wgrkcrs' cornpcnsutiorr provisions of Scctir)n 37U) of thc Lahrr Crxlc. I shall. lirrrhwith cornply with those provisions..? <br />wARNIN(i: l;ailurc lo sccurc workcrs'covcragc is unlau,ful. and shall subjcct an employcr to critninal Jrcnaltics and <br />civil lirrcs up lo onC hurrdrcd lhousand l(X).(Xn). in arltlitiott lo lhc cost oI compensation. damages as for the <br />intcrcst fccs. <br />I hcrcby alfirrn undcr pcnalty of pcrjury that I arn liccnrcd undcr provision of Chaptcr 9 (comnrcncing with Section 7m0) of Division 3 <br />of the Busincss and Profcssions Code. and my licensc is in full lirrcc and cffecl. <br />Liccrtsc' <br />Date:__ Conlractor:_ <br />CONSTRUCTI(IN LE]I\TDING AGENCY <br />I hcrchy affirm undcr Fnalyof pcrjury that thcre is a constructhn lcrding agcncy for thc pcrformnce of thc work for which lhis Ismil is <br />issucd (Scc. 3097. Civ. C.). <br />kndcr's Namc: <br />APPLICANT DFCLARATI(IN <br />I hcrcby alfrrnr undcr pcnalty of perjury one of the following dcclaratiotls: <br />Dcmolition Pcrmits-Asbcstos Notification Fedcral Regulalions (Titlc 40. Pan6) <br />-Rcquired <br />Lcttcr of Nolification <br />_l ccrtify that thc fcdcralregulations regarding asbcstos rcnrovnl arc not npplicablc to this project. <br />_l ccrtify that I havc rcad this application and stalc that thc atxrvc irtlirrrnaliott is corrcct. I agree to comply with all City arrd Cbunly <br />or<linarrccs arrd .Slatc l,aws rclaling to County to enlcr uport lhe <br />ahovc nrcrrlionctl propcrly lbr <br />Aglplicnnt or Agent <br />I'ernrilee nilnre ( prinl ): <br />rcprcscrttativcs of <br />Date:-? //r/rq <br />Site-Work <br />Underground <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bondinq I Groundinq / UFER <br />Transf ormers <br />Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Wa!ls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinss (T-Bar Rouqh) <br />N/eter Release <br />A <br />Rouqh tr//ll t ru,'Lld-/ <br />Service N/eter .-1 <br />FINAL wlxzl U1 'l-Tt^u*l firU <br />Remarks Etc. <br />ct-rnslrucl iott. <br />purposcs. <br />hercbv aulhorizc.-7 <br />v