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ELECTRICAL.I NSPECTOR RECORD <br />)nJri <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DETTARATION <br />I hscby affm und6 poalty of pqjury thd I m qcmpt ftom thc ContrrctoB' Liccnse llw for thc following wn (Se.7031.5 <br />Busine md Profeion Codc): Any City or County which requiE a psmit to @Gtruct, 8ltq, imprcvg donolish or rcpair ay <br />structuc. prior to its isumcc. also rcquire thc applicut for such pcrmit to 6lc a signcd statmt thal hc or $c b licqBcd pswt <br />to thc provisioG of thc Contractq'! Liccnscd llw (Chaptq 9, Comcncing with Setion 7000 of Division 3 of thc Bwin6 ud <br />PrcfcssionsCodc)orthathcorsheisqcmptthcfromudthcbosisforthcallcBcdcxmptio[ AnyviolationofSdiotrT03l.5bymy <br />applicut for 8 pcnrit subjets thc applicant to a civil pcmlty ofoot morc ths fivc hundrcd dollm ($500). <br />_1, s om6 of thc Fopcrty. or my mployc with wag6 6 thch $lc @mposalion, will do thc woil ad dE srndre G not <br />intodod or offqcd for slc (Se.7044, BEirs md Prcf6sioro Codc: ThG Contrsctor's Licffic kw do6 not rpply to e omq of <br />thc propqly who builds or imptos thmn, ed who dc reh wrt himclf or hwlf or thrcugh his or ho om cmploye, <br />provided that such impovsrcots rc rct intadrd or olfacd for slc. lf, howffi, thc hilding or impovamt is rcld within on. )ar <br />ofcomplaion, thc Own6 Buikb will havc tlrc hrdar ofproving thd hc or shc di, mt hrild or irprow the propqty for thc purposof <br />slc). <br />-1, <br />I oM6 of thc Fopqly, m cxclNivcly contracling with licscd contractoE to construd thc Fojet (Sc. 7044. Buins <br />ud Proftsslm Codc: The Contructor's Licffic Law doB not spply to m ownq of propdly who builds or improv6 th6@n, <br />md who contnctg for such prcjets with 8 Cotrtmao(s) licascd pm@t to thc Contrsc.tor's LiccN Law). <br />I m cx@Dt udq Setion-, B. & P.C. for this rcen. <br />l)nte:Owner,_ <br />WORKERS' COI}IPEN <br />DECLARATION <br />one of the following declarations:I hereby affrrm under penalty of perjury <br />_l have and will maintain a Certificate of Consent to Self-lnsure for workers' conrpensalion, as provided for by Section 3700 of the <br />Labor Code, for the p€rformance of the work for which the perrnit is issued. <br />-l <br />have and will 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 issuod. My workers' compexsation insurance carier and policy numkr are: <br />Policy Number: Expires: <br />_l cerrify that in the performance of the work for rvhich this permit is issued. I shall not employ any person in any manner <br />so as to become subject to the workers'compensation laws of California. and agree that if I should become subject to the <br />work6s' compensation provisions of Section 3700 of the tabor Clode. I shall. forthwith comply rvith those provisions.. <br />WARNING: Failure to secure workers' compensation coverage is unlarvful. and shall subject an onployer to oiminal penalties and <br />civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation, damages as provided for the <br />Section 3076 of the l-abor Code. interest and attorney's fees. <br />Drte: Applicent: <br />LICENSED CONT]IACTOR <br />DF'CI AR"ATION <br />I hereby affrrm under penalty of perjury that I anr licensed under provision of Chapto 9 (cornmencing with Section 7000) of Division 3 <br />of the Business and Professions Code, and my license is in full force and effcct. <br />Class: License Number:License <br />Date:Contractor:__ <br />W <br />I hrcby affm undr penalty of pcrjury that thqc is a construction lmding agocy for thc pcfomcc of the rcrk for which this Ipmil b <br />issucd (Se. 3097, Civ. C.). <br />Lender's Narne <br />Lender's Address: <br />APPLICANT DECLARATION <br />I hereby affurn under penalty of perjury one of the following declarations: <br />Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) <br />-Required <br />Letter of Notification <br />-l <br />cdiry thal the fcd68l rclulatioB rcgading Bb6tos rmoval uc not applicable to this prcid. <br />-l <br />cdiry thd t havc r€d this application Erd statc thd thc abovc infomlion is corcl. I agre to comply with alt City md County <br />ordinancG ed Statc kws rching to builditrg constructio[ md hscby authoriz rcprffitdivc of this City md Couty to atq upoo thc <br />sbovc m@tioned prcpcrty for impoction purpos. <br />Applicant or Agent <br />Perrnitec nanre (prinl ): <br />Dnte:_ <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm I Dampers <br />Communications Cable <br />Building <br />Under SIab / Floor <br />Bonding I Grounding / UFER <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Roush) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilings (T-Bar Roush) <br />Meter Release <br />Rough <br />Service Meter IFINAL tZ /tl-/"r^2?O ,4 '{MtYl/ <br />Notes, Remarks,'Etc ,l <br />rlc