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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER EUTLDER DELCARATION <br />I hcrchy atlirm undcr Fnalty of lcrjury that I m excmpl lrum thc ContrackrB' Liccns law tbr lhc fbllowing ltam (Se.70J1.5 - <br />Busincss and Professhn Cule): Any Cily or County which rcquircs a JEmrit kr rrnslruct. aller. in{rruvc. dcmolish or rcpair anL <br />struclffc, pri(rr to ils issuancc. aL$ rcquircs the applicanl lirr such lrcrmit to filc a signed s(atcnEnt that hc or shc is lienscrl pusuarlT <br />to thc provisions of the Contractor's Liccnsd Law (Chaptcr 9. Commencing with Secti(rn 7(Xl0 of Diviskln J of thc Busincsr,lnd ' <br />ProlcssionsCulc)orthalheorshciscrcmplthercliomandthchnsistirrthcallcgcdcxcmption. Anyviolationofsftti(tn70.11'.5byany <br />applicanl ftrr a Jrmil subjccts lhc applicant to a civil pcnalty ofnot nDrc lhan five hundrcd dollds (S500). <br />_1. as owner of'thc pn)pcrly. or my cmployces wilh wagcs as thcir sole compnsation. will do lhc work aftt thc struclurc ls not <br />ilttcndcd or ofi'ered tbr salc (Scrc.7M4, Busincss and Pr<ltbssions Crx.le: 'l'he Contractor's Liccnse Law docs not apply lo an owncr ol'. <br />thc pnlJray wlxr builds or impnrvcs thcrcon, and wlxr dtrcs such work himsclf or hcrsclf or through his or her own cmployecs. <br />providcd that such impnrvcrncnts arc not furtendcd or ol'tcrcd tilr salc. Il, howevcr, thc huikling or improvcrncnt is sold within onc ycar <br />of complctkrn, thc Owner Buiklcr will havc thc burdcn of proving lhat hc or she did rurt build or improvc the prupcrry tbr thc purJxrsc of <br />sah). <br />_1, as owner ol'lhc pnlpcrty, am exclusively contracting with liccnsctl contraclors to conslruct thc projcct (Sec. 7(X4, Busincss <br />and Pnrtbsskrn Codc: Thc Contraclor's Liccnsc Law docs not apply to an owncr <lf property wlto huikls ttr intproves thercon. <br />anrl who conlracts lbr such projccts with a Conlractor(s) liccnscd pursuant to thc Conlractor's Licensc Law). <br />-lantcxcntptuttdcrScctitln-.I}'&P'C.tilrlltisrcasrln. <br />Dale : Owner: <br />}V O RK EI(S' CON I PF:NSATIO N <br />DECI,ARATION <br />I hcrcby atl'irnr undcr Jrcnalty ol'Jrcrjury onc o[ thc lirllowing dcclarations: <br />_l havc antl will maintain a Ccrtificatc of Consent to Scll'-lnsurc lbr workcrs' comlrcnsalion, as providcd tilr by Section 1700 of thc <br />Latxrr Codc, tbr the lrcrlirrmancc of thc work tilr which thc Jrcrmit is issucd. <br />_l havc and will nraintain workcrs' comJrcnsation insuralrcc, as rcquired by Scction J700 of the Labor Codc, lilr thc pcrlorntancc of <br />thc wrlrk lirr which this Jrermit is issucd. My workcrs' conrpcnsalion insurance carricr antl pllicy number arc: <br />Policy at,/=l ) /'oile( -'r <br />_l ccrtily that in thc perklrmancc of thc work ftlr which this Jrcrmit is issucd, I shall not empk)y any [rcrson in any manner <br />so as to bccome subjcct to the wrlrkcrs' contJrcnsation laws ol'Calilirrnia, and ilgtce lhat if I should hccomc suhjcct to lhe <br />workcrs' comlrcnsation pnlvisions of Scctirln J700 of thc [-ahlr Ctxlc, I shall. lirrthwith comply with thosc pnrvisions.. <br />WARNING: Failure to sccurc workcrs' conrpcnsation covcragc is unlawlul. antl shall sub.jcct an cmpktycr t() criminal pcnalties and <br />civil lincs up lo onc hundred thousand dollars in addition to thc cost of cttmgrcnsation,as provirlcd tirqthc <br />Scclirxr 107(r ol'thc Latxrr Crxlc, inlcrcst and t'ces. <br />oot <br />I hcrcby allirm under Jrcnalty ol'pcrjury that I am liccnrcd under pnrvision of Chaptcr 9 (commcncing with Scction 70m) of Division 3 <br />of thc Business and Prol'cssions Codc, arul nry license is in full lirrce aml efl'cct. <br />Liccnsc Numhcr:\o (sEce <br />Dil", pa/?< J4 <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby allfum undcr Jrcmlty of Jrcrjury rhar rhcrc is a c$nstructk n bnding agcrey lbr thc trrli)mr&! of thc Mlrk hlr which lhis JEmit Ls <br />issucd (Scc. 1097, Civ. C.). <br />[rnder's Name: <br />[rntlcr's Adtlress: <br />APPLICANT DECLARATION <br />I trcrehy alfrm unrler pcnalty of prjury one of thc following declarations: <br />Dcnxrlition Pcrmits-Ashcstos Notification Fcdcral Regulations (f itle 40, Parl6) <br />_Rcqu ircd lrt tcr ol' Notilication <br />_l certity that lhc lbdcral rcgulations rcgiuding asbcstos rcnxrval arc not applicahlc to this pntjcct. <br />_l ccrtily lhal I have rcad this application and statc that thc ahrvc inlirrmation is corrcct. I agree to comply with all City and County <br />ordinancc's and Statc Laws rclating to hcreby autlxlrizc rcprcscntativcs ot'this City and County t() entcr uSxrn the <br />alrovc nrcntioncd pnrJrcrly lirr ) <br />Applicant or Agent <br />Penrritrc nnnre <br />conslntcl <br />Site-Work <br />Underground <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 Slab / Floor <br />Bonding I Grounding I UFER <br />Transformers <br />Torqueinq - ,a7 <br />Sub-Panels -24412r.) <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit)a <br />)n1'b ,\ a/,)/ <br />Walls (Rouqh)/\n- 2 wnfrry <br />Ceilings (Hard & Soffit Rouqh <br />Ceilings (T-Bar Rough) <br />Meter Release <br />Rough <br />Service Meter A <br />FINAL b--61 *7a ult+-l[,1 <br />Etc. <br />na n7 1fl.i x <br />^ .:-, rZ,*. -a-n -.- . ^) <br />,,,.t",cntz/q