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ELECTRICAL.INSPECTOR RECOR D <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUII-DER DELCARATI0N <br />I hcrcby alfirm undcr pcmlty of pcrjury that I am cxcmpt fmm lhc ('onlrflclon' Liccnsc [-aw for lhc li)llowirg rcasn (.Scc.?0:]1.5 <br />Busincss und Profcssion Codc): Any Cily or Counly which rcqui,cs a pcrnlil k) construcl. alter. improvc. dcnrolish or rcpair any <br />slruclure.priork)ils issuancc.alsorcquircslheapplicrnllbrsuchFrmiltolileasigncdslatctrcnl IhatlEorshcisliccDscd pursuant <br />to lhc pmvisions of thc Contractor's l"iccnscd bw (Chaplcr 9. Conrmcncing wilh Scction 7fin o[ Division ] of thc Busincss and <br />PmlcssioosCodc)orlhalhcorshciscxcmptlhcrcfronrandlhchasisforlhcallc8cdcxcrnftion. Anyvk)lationofScctionT0-ll.5byany <br />applicailllbr0fcrrlitsuhjcctsthc applicanttoacivilpcnaltyofnotnx)rcthanfivchundrcddollars(S5(D). <br />_1. rs owncr of thc propeny. or my cmpk)yces wilh s'ages as thcir solc conlpcnsrli(m. willdo thc work and lhc strulurc is not <br />inlcrrdcd or oflcrcd for salc (5(.70.14. Busincss and Profcssions C(xlc: Thc G)nlrack,r's Liccnsc Law docs nol alply b an owncr of <br />thcpmFny whobuildsorimprovesthcrdnr.mdwhodocssuchworkhirnscl[orhcrsclforthroughhisorhcrowncmpbyccs. <br />providcd that such imp()vctrrnts m nol inleftlcd or olLrc{ for salc. lf. howcvcr. thc buildirrg or impro\cnEnt is sold within one ycar <br />ofconrplctkrn. thc Owncr Buiklcr will havc thc burdcn ol proving thal hc or shc did nol huiH or inprovc lhc pmFrly tbr thc pur[nsc of <br />ulc). <br />-1. <br />rs owncr of lhc profcrly. am cxclusivcly conlraclin8 with Iiccnscd collrock)rs lo conslnrcl Ihc projccl (Scc. 71)4i1. Busrncss <br />ilril Pmlcssi[Codc:ThcContrack)r's[,iccnsct-{wdocsnolapplyloatrowncrofpropcrtywhohuildsorimprovcslhcrcon. <br />and who conlrrcls li)r such pr(riacls wilh u Cor{rrclor(s) liccnscd pursuanl k) lhe ('onlrrckrr's l,iccnsc l;rw). <br />-IamcxemplunderSccti()n-.B,&P.C,lbrlhisrcason,I)ale:0wner: <br />lV()RKER.S' COlltPDNSA'IION <br />DI'CLARA'I'ION <br />I hcrcby alfirnr undcr pcnalty ol pcrjury onc ofthc folkrwing rlcchrations: <br />-lhavcandwill <br />mainlainrCcflilicatcofConscnl bSclflnstrcfrrrworkcrs'compcnsrtion.as providcdforbyScctir)il37tX)ofthc <br />l,ak)r Codc. for I he pcrformilncc of thc work for wh ich I hc rcrmit is is\ucd. <br />-l <br />havc and will maiilflin workcrs' conlpcDlalion insurrncc. us rcquircd hy Scction J7(X) ol thc lrhor Codc. for thc pcrfornmncc ol' <br />thc work for which lhis pcrnril is issucd- My workcrs' compcnsaliu insuralcc crricr ilil(l fmlicy rrumbcr iuc: <br />F.-xnircs:Policy NumtEr: <br />-l <br />ccrlily lhat ir thc pert)rnlancc of lhc work for which lhis pcrmil is issucd. I shall not cnrploy any pcrsoil in any ilranncr <br />s ar b hcconr subjccl k) lhe workcrs' compensati()n laws ol Caliti)rnia. and sgrcc thnt if I should bccotrrc subjccl to thc <br />workcrs' conrpcnsalion provisions ofScclion 37(x)ol lhc l-atnr CGlc. I \hnll. Ii)nhB,ilh conrply with thos provisions.. <br />WARNINGT Failurc lo securc workcrs'conrFnsalion covcragc is ullaulul. und shilll suhjcct {n cnlploycr k) criminill frcndliies and <br />civil lincsupbonehundrcdthousanddollars($l(n.U)0).inadditioniolhcco\lofconrJrcnsalion.damagesaspr(,vidcdforthe <br />Scclion J076 of thc htx)r Codc. ttcrcst and iltbrncy's tccs. <br />D8l€r_,\pplicnnl: <br />I ICENSEN CONTRACTOR <br />DFCLARATION <br />I hercby al'lirnr undcr pcnahy of Frjury that I am licclsd !ndcr p()vision of Chaplcr 9 (connrcncing with Scction 7(XX)) of Division 3 <br />of lhc Busincss and Profcssions Codc. dnd my liccnsc is in full fore and effcct. <br />Liccnse Class: Liensc Number: <br />Dsle: Cotrtnc'lor: <br />CONSTRUCTION I ENDINC AGENCY <br />I hcrcby affirm undcr pnalty ofperjury lhat thcre is a conslruction lcndin8 agency for lhc pcrfornuncc of thc work for which lhis Jrcrmit is <br />issued (Scc. 3097. Civ. C.). <br />lrndcr's Nrrnc: <br />Lcndcr-s Addrcs\: <br />APPLICANT DECLARATION <br />I hcrchy allirrn undcr penulty of pcrjury one of lhc folhwing dcclaralionsi <br />lXnxrlition Pcrntits-Asbcslos Notiticati(m Fcdcral Rcgulalions (Tillc 40. Pan6) <br />_Rcquircd lJncr ot Noliticalbn <br />_l ccaily lhrl lhc fcdcralrcSulations rcgnrdinB ashcsbs rcrnovrltrrc nol rpplicthlc to this pro.iccl. <br />-l <br />ccf,ily lhat I havc rcad this application od slatc that thc nk)vc informalion is corR-t. I agre to cotnply with all City and County <br />ordinilmcs and State Lrws rclating to building construclion- and hcrchy authorize reprcscnlativcs oflhis City and County to cnler upon thc <br />alDvc nrcnlbncd propcny for inspcclbn purF)scs. <br />ApplicaDl i)r Agcnl Signalure.Dale: <br />Pcrntiler namc (prinl): <br />Site-Work <br />Underground <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safetv /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Transformers <br />Torqueino <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouoh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinqs (T-Bar Rouqh) <br />l/leter Release <br />Rouqh <br />Service lvleter t <br />FINAL 7 /zz/ 14 LfaINotes, Remarks, Etc