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ELECTRICAL-INSPECTOR RECORD l
<br />APPROVALS DATE ID/SIG.COMMENTS OWNE,R BUII,I)IiR DIiI,CARATION
<br />I hereby affrnr urrtler penalty of perjury that I am exenrpl fronr lhe Contractoru' License [:w for the following reason (Sec.7031.5
<br />Business and Prol'ession Crxlc): Any City or County which rcquircs a pcnnit to construct, altcr. irnprovc. demolish or repair any
<br />structure, prior to its issuance. also requires the applicant lirr such permit to file a signed slatenEnl that lr or she is licenscd pursuanl
<br />to the provisions of thc. Contractor's l,icensed law (Chaptcr 9. Commcncing with Section 7fi)0 of l)ivision 3 of thc Business a5d
<br />Professiclns Code) or that lrc or slrc is exenpt tlrcrefronr and tlrc basis for tlre alleged exenption. Any violation of Section 703 1.5 by any
<br />aplicant for a pennit subjects the applicant to a civil penalty of not more than llve hundred dollars ($5tXl1./
<br />V-l.as owncr ol'tlrc protL-rty. or my crnployecs with wagcs as lhcir sote compensation, willdo thc work and rhc structure is not
<br />iutenderl or offered ftrr sale (Ser'.70{4. Business and Professions Cqle: The Contraclor's License Law does not apply to an owner of
<br />the progrerty wlxr builds or inrproves tlrreon, arxl wlxr drus such work himself or lrerself or through his or lrcr owrt entployees,
<br />providcd that such improvc.nrcnts arc not intendcd or ollcrcd for salc. Il. howcvcr, the building or inprovcnrcnt is sold within one ycar
<br />of completion" the Owncr Buikler will have the burden of pmving thal hc or she did not buikl or improve fic propaty for thc purpose of
<br />sale).
<br />_1. as owner of the properly, anr exclusively contracting with licensctl conlraclors to construct thc pruject (Sec. 7044. Business
<br />arxl Protessitrrr Code: Tlre Contractor's License Law des n()t apply to an owner of proJrerty wh<l builds or intproves thereon.
<br />and who contracts lor such pnrjccts with a Contracto(s) liccnsed pursuant to thc Coilractor's License l-aw).
<br />_[ anr exetnpt under Sectit,n_, B. & P.C. tbr tltis reasott.
<br />Dste: 1-?O'LO n*rr"r, E;ldA 0Ch0d
<br />WORKI'ITS' COMPENSATION
<br />lherebyaffirnrun<lcrpcnaltyofpcrjuryoncofthe,o,,o*,ffi
<br />_l have and will nuinlah a Certilicate of Consent to Self-lnsure for workers' compensation, as prcvided for by Section 3700 of thc
<br />Labor Codc, for thc pcrfornunce of thc work lbr which thc Jrcrmit is issucd.
<br />_l have and will ruaintain workers' conrpensation insurance, as required by Section 3700 of the [:b,or Code, for lhe perfonmnce of
<br />thc work for which this lrcrnrit is issued. My w<lrkers' conryrcn.sation irusurancc carrier arxl plicy nuntbcr are:
<br />Carrier:
<br />Policy Number: Expires:
<br />_l ccrtify that in thc;^*rlornuncc of thc work for which this pcrmit is issucd, I shall not employ any person in any manncr
<br />so as to bccomc subjcct to the workcrs' compensation laws of California. and agree that if I should becolne subjcct to the
<br />workers' conrlrnsation provisions of Section 3700 of the Labor Cqle, I slrall, forthwilh comply with th<rsc provisions..
<br />WARNING: Failure lo liecure workers'
<br />civil fines up lo orrc hundred thousand
<br />compensation coverdgc is unlawful, and shall subject an cmployer to criminal penahies and
<br />dollars ($100.000). in addition to the cost of comgrcnsalion, danuges as provided for thc
<br />Section 3076 of the Latnr Codc, intcrest and attorncy's [ccs.LI dn oc-hoao*", '1 '20 -ZO l ---t:
<br />LICENSED CONTRACTOR
<br />DIiCI,ARATION
<br />I hereby affirnr under pnalty of perjury that I anr licens,ed under provision of Chapter 9 (conrrnencing with Section 7000) of Division 3
<br />o[ the Business and Prolessions Code. and my license is in full force and effect.
<br />License Class: License Number:
<br />CONSTRUCTION LENDTNG AGENCY
<br />I hercby allirrn undcr ptnatty of pcrjury that therc is a construction lcnding agency for the pcrl'orrnancc of thc work for which this per,nit is
<br />issued (Sec. 3097. Civ. C.). D
<br />l-ender's Nanre:
<br />l.cnder's Address:,.t
<br />APPI,ICANT DECI,ARATION
<br />I ffiy affrm undc'r frnalty of pcrjury onc of thc folkrwing dcclarations:
<br />Demolition Pcrnrits-Asht'stos Notification Fcdcral Rcgulations (Titlc 40, Part6)
<br />_Requircd l,cttcr of Notification
<br />_l certif that thc fcdcral rcgulations rcgarding a.sbcstos rcrnoval iuc not applicablc to this projcct.
<br />_l ccrtily tlral I havc rcarl this application and statc tlral lhc ahrvc infonnaliott witlr all Cily and County
<br />and County to enter upon thcordinanccs and Statc Laws rclating to building construction, aml
<br />above mcntioned propcny frrr inspection
<br />Applicant or Agent
<br />I'crmitec nanre
<br />lL ort", '7'20 -2O
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under SIab / Floor
<br />Bonding I Grounding I UFER
<br />Transf ormers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factorv Wired Unit
<br />Wd!s (Conduit)I I tl 1r\,
<br />Walls (Rouqh)317,tr u 'Drr4ry /
<br />Ceilings (Hard & Soffit Roush I
<br />Ceilings (T-Bar Roush)
<br />N/eter Release
<br />Rouqh
<br />Service [Vleter Ir ,l ,,
<br />FINAL 'Ll'ru DRrlr>/
<br />Notgs, Rpmarks, Etc. t -l 2\
<br />a
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<br />Rev. 08-07-201 5
<br />f-l)n Ar lnnA
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