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ELECTRICAL-INSPECTOR RECORD <br />Rev. 08-07-2015 <br />APPROVALS DATE ID/SIG.COMMENTS OWNI'R B I.'II,DER DI'I,CA RATION <br />I hereby affirnt unrler penalty of prjury that I arn exenrpt fronr the Contractors' License Law for the following reason (Sec.7031.5 <br />llusincss and Prol'ession Cocle): Any City or County which rcquircs a Jrcrrnit to construct, altcr. itnprovc. dernolish or rcpair any <br />structure. prior to its issuance. :r[so requires tlrc applicant lbr such penuit to fih a signed slatement that lr or she is liceuscd pursuanl <br />to thc provisions of thc Contractor's l,icenscd law (Chaptcr 9. Comrncncing with Scction 7000 of Division 3 oI the Busincss and <br />Prcfessions Crxle) or that he or slre is exen4rt tlrerefronr and tlrc basis for tlrc alleged exenption. Any violation of Section 7031 .5 by any <br />npplicunt for a pcnnit subjects the applicunt to t civil penalty of not rnore than five hundred dollars ($5m). <br />_1. as owncr ol'thc propcrty. or tny crnployccs with wagcs as thcir solc compcnsation, willd<l thc work ard thc structure is not <br />irrtcriled or offered frrr sale (Sec.7(X4. Business antl Professiorrs Code: Thc Clontractor's Licensc Law does nol apply lo att ownet oI <br />the pruperty wlxr builds or improve.s tlureon, arrd wlxr does such work himself or lrerself or through his or her own entployees, <br />prol'idcd that such irnprovcrrrcnts arc fi)t intcndcd or ollercd for sah. Il. hou'cver. thc building or furprovcnrnt is sold wilhin one fl-ar <br />of comphtkrn, tlre Owrcr Buikler will have the burtlen of pruving thu he or slrc did mt build or improvc the pnrpcny for thc puryose of <br />safc'). <br />fr. .:; owner of the proprty, am exctusivety contracting with licensed contraclors to construct thc project (Sec. 7(X4. Business <br />aIr,J Pnrtessiorr Ctxte: The Contractor's License l-aw does not apply to an owner of proyrcrty wlxr builds or intproves lhereon. <br />and who contracts fcrr such pr<{ccts with a G)ntractor(s) liccnscd pursuant to thc Glntractor's License Law). <br />_l anr uuder 'P*" <br />(L x <br />woHk ilhs'tr ln r pr:xsnlrorr <br />I hcrcby affirnr under pcnalty of pcrjury onc of thc following declarations: <br />_l have arxl will nuintain a Certilicate of Consent to Self-lnsure for workers' con4rcrsation. as provided for by Scction 3700 of the <br />l-ahor Code. for thc pcrformancc of thc work for which the permit is issued. <br />_l havearrd will nrainlain workers'conrpermalion insurarrce. as required bySectiorr3T00of llte LaborCode, ftrrthe lrcrfornntrceof <br />tlrc work krr wlrich this lrcrruit is issuctl. My workcrs' con4)cnsation insurancc can'icr arxl gtlicy ttunrbcr arc: <br />Policy Numbcr: lixpires: <br />pt ,"nifyttrat in thc 1a-rtirrnrancc ol'thc work firr which ttris pcrmit is issuctl, I slmll not cnrploy any lrcrson in any matlncr <br />{fo astobccolrrc.subjccttothcworkcrs'cornpcnsatiorrlawsofCalifiornia.attdagrecthatiflshouldhccomcsubjccttothc <br />workers' colulrnsation provisions of Section 3700 of the Labor C'ode, I slrall, f<rrthwith conrply with those provisions.. <br />WARNING: Failure lo secure workers' <br />civil tirres up t(, oue hurrJred lhousand <br />compensation coveraSe <br />dollars (.$100.fi)01. irt <br />unlaw[ul, and shall subject itn employer to critninal pnalties tnd <br />t<l the cust of compersation, dattuges as provided for tlte <br />.Scction thc Codc, intcrcst and atl()rncy's <br />I 2 D <br />I hcrcby affirnr under ;xnalty of perjury that I anr licensed untler provisiott of Chapter 9 (cotturcncing with Section 7000) of Division 3 <br />of the Business arrd Professiorrs Code. and rnv license is in ful! force and effect. <br />License Class: License Number: <br />Dete: <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby al'lirrn undcr pcnaltyol'pcrjury that thcrc is a construction lcnding agcncy fior thc perl'orrnancc of thc work ltrr which this pcrmit is <br />issuetl (Sec. 3097. Civ. C.). <br />[,cnder's Narrrc: <br />APPI,ICANT DECI,ARATION <br />I lucby affirru untlcr pcnalty of pcrjury onc of thc lirllowing dcclarations: <br />Dcnxrlit ion Pcrnrits-Asbt'slos Notificat ion Fcdcral Rcgulat ions (Titlc 40, Parl6) <br />-Rcquircd <br />.*r ^ttcr of Notilrcation <br />witlr all City arxl County <br />and u;xrn thc <br />All;llicant or Agent <br />l'crnritec nanlc <br />( <br />to <br />I <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 Slab / Floor <br />Bondinq I Groundinq I UFER <br />Transformers <br />Torqueinct <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 />Ceilinqs (T-Bar Rouqh) <br />lt/eter Release <br />Rough <br />Service N/eter //\\ <br />FINAL l2-[(t'vrt\\rtrl.j,t <br />N Etc.