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ELECTRICAL.! NSPECTOR RECORD <br />f)..t rto ,'t? rn { r::. <br />APPROVALS DATE !D/SIG.COMMENTS OWNERBUILDERDELCARATION ' ' <br />I hrcby affm unds pcoslry of psrjury thd I m cxmpt ftom thc ContEctoa' Liicnrc taw for thc fotlowing @n (Se.7031.5 <br />Bsin6s ad Profcssion Codc): Atry City or Couty which rcquirc a pornh to @nstruct. altc, improve dmolish or rcpair oy <br />slructre. prior to its issuucc. also rcquirs thc applicilt for such pcmit to filc a signcd statmot thar hc or shc is licqNcd psult <br />to thc provisio$ of thc Contractor's Lienrcd Law (Chapts 9. Comcncing with Sction 7000 of Division 3 of thc Busins md <br />ProfsioN Codc) or that hc or shc is cxcmpt thrcftom ad thc bssis for thc allcged amption. Any violation of Scrion 7031.5 by my <br />applicut for a pmit subjsts thc applicant to a civil pcmlty of not morc thu fivc hundrcd dollus ($500). <br />_1, 6 omq of thc propcrty, or my cmployG with wag6 6 their slc compflsalion. will do the work dd thc $rudrc b mt <br />intqrdcd or offqed for slc (Sc.7044. Busitrs md hofsioro Code: Th€ Contrector'3 Lic4c Law do6 not apply to m oma of <br />the prcpqty who builds or imprcc thq@n, aod who do6 sch rcrt himclf or hcrclf or thrcugh his or hc om mployc. <br />providcd that such improvqmb @ mt intodcd oroffrcd 6r slc. I[ hows. thc tuilding or im[ro@t is sH within onc ]sr <br />of ompklion thc o\rna BuiHq will h8w thE htrdo of proviry thd hc or dtc did mt build or improvc thc propdy for rhc purpos of <br />sdc). <br />_1. as owner am exclusively contracting with licensed Business <br />and ttofession Code:License Law does not to thereon. <br />and who contracts for such with a <br />-l <br />an Y .c. <br />I hereby affrrm under peralty of pcrjury one of the declarations: <br />_l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of the <br />Labor Code, for the pcrfonnance of the work for which the perrnit is issued. <br />_l have and rvill maintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the performance of <br />the work for which this pennit is issucd. My workers' compensation insurance carrier and policy numttcr are: <br />Policy Numbcr: ExPires: <br />_l certify that in the performance of thc work for which this permit is issued. I shall not employ any person in any manner <br />so as to bccome subject to the workers' compensation laws of California. and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall. forthwith comply with those provisions.. <br />WARNING: Failure to secure workers' compcnsation coverage is unlawful. and shall subject an employer to *,N,and <br />civil fines up to one hundred thousand dollars ($100.000).to the$st of ils for the <br />Section and <br />t hereby affirm under pcnalty of pcrjury that I arn licensed under 9 (comrnencing with Section 7000) of Division 3 <br />of the Business and Professions Code. and my license is in full force and effect. <br />License Class: Licensc Number: <br />Date, Contrectori <br />CONSTRUCTION LENDING AGENCY <br />I hrcby affm undo pcnalty of pqjury thar thEe is a corgruclion lading agmcy for thc pqfomcc of thc work for which this pqmit b <br />issucd (Sc. 3097, Civ. C.). <br />APPLICANT NECLARATION <br />I hercby affirm under pcnalty of perjury one of the following declarations: <br />Demolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) <br />-Required <br />lrtter of Notification <br />-l <br />certi[ that the lbderal regulations regarding asbcstos removalare not applicable to this project. <br />-l <br />cerlify that I have read this application and state that the above information is I <br />ordinances and State Laws <br />above rnentioned property for <br />Applicant or Agent <br />I'ernritee nanre <br />and <br />Site'Work <br />Underground <br />Pole Bases <br />Lisht Standards <br />Spas. Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltaqe <br />Fire AIarm I Dampers <br />Communications Cable <br />Buildins <br />Under SIab / Floor <br />Bondins I Groundins / UFER <br />Transformers <br />Torqueincl <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit tl ?t ,\ <br />Walls (Conduit)t l7,,lwt {-n ttrt f/ <br />Walls (Rouqh)/l/ u lYv <br />Ceilinss (Hard & Soffit Rouqh <br />Ceilings (T-Bar Roush) <br />Meter Release <br />I , <br />Rough /t Ll Z,o P tfi?/lry <br />Service Meter vl t/Al ,ao <br />F!NAL tcl/tr/eD *f_rt(,ru6dc <br />Notes, Remarks, Etc.(l <br />t <br />to the Contractor's License Larv). <br />('t \ <br />I)ate: