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ELECTRICAL.INSPECTOR RECORD <br />f,J,r'nCI n7 ?A{ E <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATTON <br />I hcrcby alfrm undcr Jrnalty of prjury that I m cxcmpt hlm thc Contrack s' Licenr law for thc following rcasn (54.70.11.5 <br />Business anl Prolcssion Codc): Any City or Counly which rcquires a ;rcmdt kr conslruct. alter, improvc. dcmlish or rcpair any <br />structurc. prior to its issutncc. also rcquirs the applicanl for such lEmil to frlc a sigrcd statcmnl lhal hc or CE is liccnsd pursuanl <br />to (hc lnrvisi(]ns of thc C(rntractor's t-icenrcd law (Chaptcr 9. Commcncing with Scction 7OU) of Division -l of lhc Business and <br />P(rfcsskrns C(xle) or that hc or shE is cxcmpl thqclrcm and thc basls tbr thc alh8ed cxcmflion. Any violalion of Sslion 70.'J .5 by any <br />applicant lirr a Frmit subjels thc applicant to a civil pcnalty of nol morc lhan fivc hundrcd dotlds ($500). <br />_1. as owncr of thc proFlcrty. or my cmpkryees with wages as thcir solc comlrcnsation. will do thc work and thc structure ls not <br />intcnded or oll'ercd lilr satc (Ssc.7(X4, Busincss and Professions Ctxle: 'l'hc Contraclor's Licensc Law drrcs not apply to an owncr of <br />thc pn)pcrty who buikls or impr)vcs thcreon. arxl who drrcs such work himsclf or hersclf or lhrough his or hcr own cmployecs, <br />provided that such inrprovcrnents arc not intcndcd oroll'cred tilr salc. It, howcvcr. thc huikling or improvcrncnt is sokl wilhin onc year <br />of complction. thc Owner Buiklcr will havc thc burdcn <lf proving thal lre or shc rlid nol buikl or intprtlvc the pnrJrcrty tbr thc purJxrscof <br />salc). <br />_1, as owncr of thc propcrty, am cxclusivcly conlracting with liccnsed conlraclors lo consltuct the pnrjcct (Scc. 7(W, Busincss <br />and Pnrlbsskm Codc: Thc Contractor's Liccnsc l-aw does not apply to an owncr o[ proJrcrty who buikls or improvcs thcrcon. <br />and who contracts lirr such projccls with a Contractor(s) liccnscd pursurnt to thc Conlraclor's Liccnsc l-aw). <br />_l am cxcmpt unrJcr B. & P.C. tirr this rcason. <br />WORKERS' CONTPENSATION <br />DECLARATION <br />I hcreby atTirm under penalty of perjury onc of thc following dcclarations: <br />_l havc anl will maintain a Certificate of Consent to Selt'-lnsurc tirr workers' compcnsation, as pnrvidcrl for by Sectkrn 1700 of thc <br />Latxrr Code, for the lrcrformancc of the work for which the pcrmit is issucd. <br />_l havc and will nraintain workcrs'insurancc. as rcquircd by Scction 17fi) of the Labor Codc, tirr thc lrcrfirrmancc of <br />thc work lirr which this Jrcrmit is issucd.workcrs' crlmpelrsation insurancc carricr arxl Jxrlicy numbcr are: <br />lL, lqPolicy <br />_t cerlily that in thc Jrcrtormance of thc work lirr which this Jrcrrnit is issucd, I shall nol cmpkly any lrcrson in any manner <br />so ils to lrccomc suhjcct to thc workcrs'compcnsation laws of Calilirrnia. and agrcc that if I should bcctlmc subjcct to thc <br />workc'rs' conrJrcnsation pnlvisions of Scction J7ffi of thc Latxrr Ctxlc, I shall. titrthwith comply with tlxrsc prtrvisirlns.. <br />WARNING: Failurc lo sccurc workcrs'conrlrcnsation covcr:rgc is unlawful, and slrall subjcct an cmploycr to criminal Jrcnaltics and <br />civil lincs up lo onc hurrdred thousattd dollars in <br />e <br />lhc of comJrcnsation. damagcs as providcd litr thc <br />Scction .1076 of'thc Lahrr Codc, intcrest and <br />! <br />I)ECI,ARA'I'I0N <br />I hcreby allrnr undcr pcnalty ol perjury that I am licenscd undcr pnrvision of Chapler 9 (conrmcncing with Sectitrn 70m) of Division 3 <br />ol' thc Busincss anrl Pnllcssions Codc, arxl my liccnsc is fur l'ull lirrce and cllcct. <br />Licc-nsc 8 Z <br />0-t- <br />W <br />I hcrcby affrm unrlcr lEulty of frrjury that tJHc Ls a @[stoctkrn lendinS agcncy for the lErfol1rlmc of the work for which lhis Frcmit ls <br />issucd (Se. 3097, Civ. C.). <br />APPLICANT DECLARATION <br />I trcrcby afilrm undcr pcnalty ol'pcrjury one tlf thc tbllowing dcclaratitlns: <br />Dcmolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (f itlc 40. Parl6) <br />-Rcquired <br />l.ettcr of Notihcation <br />-l <br />ccrtily thut thc lbdcral rcgulations rcgarding ashcsk s rcmov{l e not applicahlc k this PmFcl. <br />_l @aily that I havc read this application dxl state that thc atnve inlbrmrtion is c()ret. I agrc lo comply with all City and Counly <br />ordinanccs and Statc liws rclating to building conslructiur, ard hcrchy aulhoriz4 rcprcscntalivcs ofthis City and Counly h cnts uFrn thc <br />abovc mcntionctl propcrty lrtr <br />Applicanl or Agent <br />Pernrilee nnnle <br />Dare: luU:n <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltase <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under SIab / Floor <br />Bondins I Groundins I UFER <br />Transformers <br />Torqueincr <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Roush <br />Ceilings (T-Bar Rough) <br />Meter Release <br />Rough <br />Service Meter _t <br />FINAL / z'/4. ea K/ 4,TruE/@S %i, <br />Notes, Remarks, Etc. <br />a