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ELECTRIGAL.I NSPECTOR RECORD , <br />APPROVALS DATE ID/SIG.COMMENTS Oms-BuildqDcclruion t , I <br />I hcrcby aflim undcr pcnalty of pcrjury lhat I m cxcmpt fom thc Contracto6' Liccnsc Law for thc following rccon (se.7ol L5 Buins <br />and Profcsion Codc): Any City or Couty which rcquiro a pcmit to construct, altcr, improvc, dmolish or rcpair uy structurc. piorG its <br />issuucc, also rcquiro thc appli@t for such pcmit to filc a signcd statmot that hc or shc is liccnscd punuut to thc provisions of rhc <br />Conractor's Licascd Law (Chapiq 9, Commocing with Scction 7000 of Division 3 ofthc Businos ud Profqsions Codc) or rlrat hc or <br />shc is cxcrlpt thcrcfrm ud thc bcis for thc allcgcd cxmption .Any violation of Scction 7031.5 by uy applicet for a pcmit subjcctr thc <br />applicqg{o a civil pcnalry ofnot morc thm fivc hun&cd dollrs ($500). <br />/1, o ownc ofthc prcpcrty, or my cmploycq witl wag6 4 thcir solc compcnsation, will do thc work and thc stluctuc is not inrcndcd <br />or offacd for salc ( Scc.7044, Bwin6s od Profqsions Codc: Thc Confiactor's Liccnsc Law doe not apply to an owncr ofthc proFErty <br />who builds or improva thcrcon, ud wlto docs such work himsclf or hmclf or through his or hcr own mployccs, providcd that such <br />improvcryriG uc not intcndcd or offcrcd for salc. If, howcvcr, thc building or improvmmt is sold within onc ycuofcomplclior, thc <br />O@luildcr will havc thc burdcn of proving that hc or shc not build or imprcvc for thc purp$e of sal€). <br />ffi:::l*:'#i#;fli1il1l1tl,";H:*l'"x;lllfil:ff:Iifi:H.[,'il1ff1,["JJi*H"!:::i]111,'#";i"'o <br />contracts for such projccs with a Contrrcto(s) liccnscd pursuat to tha Contractor's Liccnsc Law.). <br />_l m cxcmpt undcr Scction .C. for this rcoon. <br />dDatc: Owncr:/tt <br />WORKERS COMPENSATION DECLARATION <br />I hcrcby affim undcr pcnalty ofpcgury onc ofthc following dcclrations: <br />_lhaveadwillmaintainaCcnificatcofConsenttoSclfJnsurcforworkcn'compcnsation,6 providcdforbyScction3TOOofthc <br />Labor Codc, for thc pcrfomacc of thc work for which thc pcmit is issucd. <br />_l havc od will maintain wqkcn' compcnsation insumcc, c rcquircd by Scction 3700 of thc Labor Codc, for thc pcrfommcc of thc <br />work for which this Fmit is issucd. My workm' compcnsation insurs& cmia ud policy numbcr uc: <br />Caricr: <br />Policy Numbq: <br />(This scction nccd not bc rcmplctcd if thc pmit is for Onc hundrcd dollm {S100) or lo) <br />-l <br />ccnify that in rhc pqfomoe of thc work fu which this"pmit is issucd, I shall nd cmploy my pcnon in any manncr so s to <br />bcmc subjcct to thc workm ' compnsation law of Califmil, md agrc that if I should bccomc subjcct to thc wqkcrs' <br />compcnsation provisions ofScction 3700 ofthc forthwith cmply with th6c proyisions.. -%* -4. 0/r"rrs <br />pcnaltics md civilWARNING: Failurc to sccurc workcm' compcnsation covcragc is unlawful, u <br />fin6 up to onc hundrcd thowod dollus ($100,000),in addition to lhc cost ofcompcnsation, damags s providcd for thc Scction 3076 oi <br />thc Labor Codc, intcrGt ud attomcy's fcs. <br />LICENSED CONTRACTORS DECLARATION <br />I hcrcby aflim undcr penalty ofpcrlury that I m liccnscd undcr provision of Chaptcr 9 (commcncing with Scction TOOO) of Division 3 of <br />thc Busincss @d Profssrons Codc, sd my liccnsc is in full forcc and cffcct. <br />Liccnsc Clus:_ Licrnsc Numbcr _ <br />Datc: Contractor <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby aflim undcr pcnalty of psdury that th6c is a construction lcnding agcncy for thc pcrfmancc of rhc wqk for which this p€mit is <br />issucd (Scc. 3097, Civ. C.). <br />Lcndcr's Nmc: <br />Lcndcr's Ad&css: <br />APPLICANT'S DECLARATION <br />Dmolition Pcmiti-Asbstm Notification Fcdcral RcSulatons (Titlc 40, Pan 6) <br />_ Rcquircd Lcttcr ofNotifietion <br />_l ccnify that thc fcdcral rcgulations rcguding sbotos rmoval &c not appliqblc to rhis projcct. <br />_ I ccrliry thd I havc rcrd this application ud shrc thar thc abovc infomtion is corcct. I agrcc to <br />ordinmcq ild Statc Laws rclating to building @nstruction, ed hqcby authorirc rcpreotativc of <br />comply with all City ild Counry <br />abovc miltioncd propc.ty <br />this City ud County to cntcr upon thc <br />Applicilt or agcnt <br />Pcmittcc nmc (print): <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Transformers <br />Torquing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soffit Rough <br />Ceilings (T-Bar Rough) <br />Meter Release <br />Rough <br />Service Meter <br />FINAL <br />Notes, Remarks, Etc. <br />r ,rf)r v nAr 17 <br />N