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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hrcby allinn undo penalty of per.jury thd I m exempt fioN the Conlractors' License taw for the following roson (Sec.70.1 1.5 <br />Buines md Profasion Code): Any City or County which requirs a ponit lo coNtrucl. altc. improve. dmolish or repair my <br />struclue. prior lo its isuace, also requird thc applicill for such pentril to file a signed statmot thal hc or shc is licosql pmuet <br />to the Eovisions of lhe Controctor's Licenscd l-aw (Chapts 9, Commencing with Setion 7000 of Division 3 of the Busincss and <br />ProfcsionsCode)orlhatheorsheiscxcmplthqefrommdtheb6isfortheallegedexonF,tion. AnyviolalionofsstionT0-1l.5byily <br />applicmtforap€milsubjststhe applicanttoacivilpcnaltyofnotmorethmfivehundrcddollds($500). <br />-1. <br />o omo of the properly. or my employe with rvage o their mle composation. will do the sort md the structue is not <br />intmdcd or offqed for sle (Ss.7044, tsusinss md Profesions Code: Thc Contractor's Licme Larv dos not apply to m owns of <br />thepruperty whobuildsorimpovethoon,ddwhodo6suchworkhimselforhsselforthroughhisorh€rownemployes. <br />provided that such impovmmts e oot intsded or offsed for slc. If howryc. the building or imgrcr'mt is old whhin onc yw <br />ofconrplaion. the Ownq Builds will have thc hrdo ofprcving that he or she did not build or improvc thc propqty for the purpo* of <br />slc). <br />-1. <br />a owner of lhe propoty, m exclusivcly contracting with liccNed contractoE to construct the proict (Ss. 7044, BusinN <br />md l'rofusionCodc:Th€Conlractor'sLicenseLawdo6nolapplylomownerofpropfiywhobuildsorimprovBthseon. <br />and rvho contmds for such projus with a ContEclo(s) licffed puEuanl to thc Contraclor's Licmse taw). <br />-ImexemptunderSetion-.B,&P,C,forthisrruon.Dfllr:()silcr: <br />I hereby afftrrn undo pcnalty ot pcjury one ofthe followinS declarations: <br />-l <br />have md rvill mainlain a Cdificatc of CoNst to Self-lNure for rvorkers' compensalion, 6 lrovided for by S(tion .]700 of the <br />Labor Code, for the psfomance of thc work for which the pmit is issued. <br />-l <br />have and will maintain workers' compecalion iNurance, r requfcd by Sation 3700 of the Labor Code, for the pofommce of <br />the workforwhichthispennit is-issued. Myworkers compflsali()ninsurancecauicrmd ;xrlicy number ae: <br />PoticyNumbcr:/- noz)2\77 Expi,6.t <br />-l <br />ce(ify thal in the ptrfomance of thc work fot which this pernrit is issued. I shall not employ any person in any mmff <br />s 6 to become subjst lo the work6' compffation laws of Califomia. ed agre lhat if I should tEome subj(t to thc <br />workm' compensation provisions ofSetion 3700 oflhe l,abor ('ode, I shall. fonhwilh comply wilh lhos provisions.. <br />WARNING: Failure to sue workm'compctsation covmge is unlarvful, md shall subiat an mployo lo aiminal penaltiG ild <br />civil hnes up to one hunded thoumd dollas in addition lo the cosl of compensation. danages o p(ovidcd for the <br />Ssrion 3076 ofthe Codc. inl66l ild <br />(\-7- <br />t)1,t( 1,,\lt,\'t t()N <br />I hereby aflinn under g)enalty of perjury lhat I an licoscd under provision ofChapt6 9 (conrrnmcing rvith Section 7000) of Division l <br />of the Busins md Profsiom Code, and my licere is in full cff(t. <br />Liccnse <br />q 3bo'5Number: <br />CONSTRUCTION LENDINC AGFNCY <br />I hmby affrm undr pnalty of perjury that thqc is a conslruclion lending agflcy for the pqfommce of the work for rvhich this pamit b <br />issued (Src. 3097. Civ. C.). <br />Lender's Narne <br />Lendcr's Addrs: <br />APPLICANT DECLARATION <br />I lreby affm undo pmalty of pejury one of the following delaations: <br />Dqnolition Pmnits-Asbetos Nolification Fedoal Regulations (Tille 40. Pan6) <br />-Required <br />Lettq of Notification <br />_l c6tify lhat the fcdcral regulations regading abelos removal are not applicable to this project. <br />_l cfiiry thal I have r@d this application ild state lhal lhe above infomlation is cord. I agrtrto comply with all City and County <br />ordinailces and State Laws relating to corelruclion, md hercby aulhorize represcntativ6 oflhis (-ity and Counly to entq upon the <br />above motioned propeny for <br />Applicatrl or Agmt v 7 <br />/ zrue/ <br />_ Dste: <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bonding / Grounding / 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 />Ceilings (Hard & Soffit Rouqh <br />Ceilinqs (T-Bar Rouqh) <br />Meter Release <br />Rouqh <br />Service Meter I n I A,4 / //h <br />FINAL t&l+4tffi qVY- l/a EQul /f)u}/ry /// 7//( <br />Notes, Remarks, Etc]T <br />0,..,, flo t\-, t)t\attl <br />I)ater t Con(raclor: <br />I'crtrrilcc nanre (print):