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ELECTRICAL.INSPECTOR RECORD <br />f),ta n7 Dn{ H <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARA'I'ION <br />I hcrcby affirnr undcr lrnalty of pcrjury th{l I am cxcmpt fmm lhc Contraclos' l-iccnsc tlw for tlrc following rcasn (Ss.7O-11.5 <br />Busincss ard Profcssion Codc): Any City or County which rcquircs a prmil lo construcl. alt6, inurrovc. dcmlish tr rcpair any <br />struclurc. Jrhr to ils issuance. also rcquircs thc applicant for such lrcrmil to lilc ! signcd slalemnl lhat hc or shc is liccnsd pursudnl <br />to thc pmvisions of lhc Contractor's Liccnsed lnw (Chaptcr 9. Commcrcing wilh Scclion 7000 of Division -1 of lhe Busincss and <br />Profbssions Codc) or rhil he or she is excmpt thcrcfrom and thc basis for lhe allcgcd cxcnrption. Any violation of Scclk)n 703 L5 by any <br />applicant for a pcnnit subjsls thc applicant to u civil pcnaltyof not mrc than fivc hundrcd dolltrs ($5fi)). <br />_1. as owncr of thc proprly. or nly enlployccs wilh wagcs as thcir sole compcnsation. will do thc work and thc structurc is not <br />intcndcd or offcrcd lor salc (Scc.7044. Business and Prol'cssions Codc: Thc Contraclor's Liccnse Law docs nol apply to an owner of <br />thc propcrty who builds or improves thcrcrrn. and who docs such work hinrsclf or hcrsclf or lhrough his or hcr own employces. <br />providcd that such irnprovcnrcnls arc not intendcd or olTcrcd for salc. lt. howcrcr. thc building or improvcrrnl is sokl within one yeiu <br />of comphtir)n. ttrc Owncr Builder will have thc burdcn of proving thal hc or shc did not huild or improve the proJrcrty for thc purpsc of <br />salc). <br />_1. as owner of thc propcrty. am cxclusivcly cotrlracting with liccnsecl contraclors lo construct thc projccl (.Scc. 7()44. Busincss <br />and Pnlt'csskrnCoclc: 'l'hc Conlractor's Liccrrsc Law docs not applyto anowncr o[properlywho builds or intprovcs lhcrcon. <br />arrd who contracts lbr such projects with a Contractor(s) licenscd pursuant to thc Conlractor's Liccnse Law). <br />I am exemnt <br />Date:_ <br />undcr Scction-. B. & P.C. fpr this rcason. <br />- ,wner,-p\- K,^/*4 Pd'/-e <br />WO RKERS' COIIT PENSATION <br />DECLARATION <br />I hcrchy all'irrn undcr pcnalty of pcrjury onc of thc lolkru'irtg dcclarations: <br />_lhavcandwill rnaintainaCertificateo[Conscntt<l .Sclf-lnsureforrvorkers'cornpcnsation.as providcdforby.Seclion-]700ofthc <br />Labor Code. for the pcrformancc of the work for which thc perrnit is issucd. <br />-l <br />have and will rnaintain workcrs'cornpcnsation insurancc. as requircd bySccti<ut 37ffiof lhc LaborCoclc. forthc pcrfornunceof <br />thc work for which this pcrrnit is issucd. My workcrs' compensati<ln insurattcc carricr and Jxrlicy number arc: <br />Policy Number: Expires: <br />_l ccrtily that itr lhc pcrtirrrnance of thc wrlrk lirr which this pcrrnit is issucd. I shall nttl cnrploy any pcrson in any tnanner <br />so as to bccornc subjcct to the workcrs'cornpcnsalion laws of California, and agrcc lhat if I should bccotttc subjcct to lhc <br />workcrs' corrrpcnsation provisions of Section 3700 ol'thc [.ahlr Codc. I shall. lirrthwith comply with thosc provisions.. <br />WARNING: Failurc to sccurc workers'cornpensati()n covcrage is unlawl'ul. and shall subjcct an crnployer to crirninal pcnaltics and <br />civil fincs up to onc hundrcd thousand dollars ($l(X).fiXlt. in addition lo lhc cosl of conlFrcnsation. dantagcs as providcd for thc <br />Scction 3076 of thc Latxlr Code. intercst and atlorlrcy's l'ces.f /ry*Date:_Applicant: <br />DECLARATION <br />I hercby alfirnr under pcnalty of perjury that I anr liccnscd undcr provision of Chaptcr 9 (contmcncing with Scction 7Un) of Division 3 <br />of thc Busincss and Professions Code. and my liccrrsc is in l'ull tbrcc and effect. <br />Licensc Class: Licensc Numbcr: <br />Date: <br />W <br />I lrcrcby sffrm under pcnatty of perjury that thcre is a @nstructbn lcnding agcncy for thc ]Erformne of lhc mrk for which this pcrmit is <br />issucd (Scc. 3097, Civ. C.). <br />hndcr's Nanrc: <br />lrndcr's Address: <br />APPLICANT DECLARATION <br />I ffiy affirm under penalty of perjury onc of thc following dcclarations: <br />Dcmolition Pcrmits-Asbcstos Notification Fcderal Regulations (Title 40. Part6) <br />_Required [rttcr of Notification <br />-l <br />ccrtify that thc fcdcrslrcgulations rcgading asbeslos rcmvalarc not applicahlc lo this prcjert. <br />_l ccrtify thal I hBvc rcad this application ard state thst lhc .tnve infomtion is corrccl. I sge to @mply with all City and County <br />ordinares and Statc Laws rclating to building coNtruction. 8rd hercby authori4 rcprcscnlaliws of this City and County to cnts uIDn thc <br />ffi*I-:il: *," dzt/tt <br />Permitee name ( prinl): ___ <br />Site-Work <br />Underqround <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under SIab / Floor <br />Bondinq I Groundi nq I 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 Rouqh) <br />N/eter Release v 'dn 5-na l;4r1 , Rk <br />Rough <br />Service N/eter <br />FINAL Uto ltll -ftrLa,{2il ) <br />Notes, Remarks, Etc.I I I VU \t/ <br />Contractor:_