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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/S!G.COMMENTS OWNIIR BUILDI.IR I)l'ILCARATION <br />I hercby affrnr untler penalty ofperjury (lrnt I anr exenrpt fron lhc Contractos Licensc Law for thc followillg reasorr (Sec.7031.5 <br />llusincss and Proltssion Codc): Any City or County which rcquircs a pcrtnit kt conslrucl. altcr. improvc. dcmlish or ri'pair any <br />struclurc, prior k) ils issuaDcc. aLso Equire\ tlE applicatrt lbr such Fnlul to file a sitiled slalcnEilt that lE or she ir licctlEd pusuanl <br />to thc previsionr ol'tlE Conlrac()r's l-iccnscd l;w (Chaptcr 9. Cotnrncncing wilh Section 7000 ol Division J ol thc Busincss and <br />PlofcssionsCodc)orthrtheordlcisexcn)l)(llrrefiomaDdtlEbasistbrllEalleSedexenlptiur. AnyviolatiulofSectiuT0Sl.5hyaty <br />applicantlbruJrnnirsubjecrstlE applicanttoacivilpennllyofnotrmrethanfivchundreddollars($500). <br />_1. as owner ol'th(' prolt(y. or my ernployccs with wagcs as thcir $lc comlEnsalion, will do rhe work ad thc stmue is mt <br />intcndcd or offcrerl f<rr salc (Scc.7044, Busincss atrd Prufcssions Codc: Thc Conlraclor's Liccnsc Law docs not apply lo e ownd of <br />the pn)trr1y wlp huilds or imp(rves the!&q ud who dcs such wo* himself or lErself or lkouSh his or lEr own enrploycest <br />providcd that such improvcrEnts dc mt intcrdcd or ollc(a, for sh. ll. howcvcr, 0r toildinS or ifiprovemnt is $ld within ore )€il <br />ofconsbtio[ thc OwrEr Buikkr will hav. thc borden of psving that h. or ihe did rct b{ild or irprcvc 0E prepqly fo. th. purpo* of <br />sale ). <br />-1. <br />as owncr of thc propeiy, sm exclusitcly contracting with liccMd contracloB lo construcl lhc prcject (Sac. 7014. Busincss <br />arxl h$lision Code: The Grnlracbr's Liceose Law d(Es not apply to an owrer of proFrc(y *ho builds or ioprovcs lhercon. <br />and who contmcls for such proiccts with a Con(rack)(s) liccn*d pursumt to tlrc Conuactor's Licensc kw). <br />-Ian)excmptundersecli(nt-,B,&P,C,l([tllisreason, <br />woRKti,Rs' coMPuNsA't I0N <br />DECLARATION <br />I hcrchy allirnr utr(lcr pcnally r)f pcrjury onc 0l thc li)lk'wing dcclMati(xrs: <br />_l haveMdwill truinlainaCenil'icaleofConsentoSclFlnsurcf(,rworkers'conrpeNation,as prcvidcdforhyScctionST00ofthe <br />htpr Codc, Ior thc pcrfornmcc of lhc work lor which lhc pcfldt i\ irsucd. <br />_lhavcardwill nhintainworkers'conrpcnsalioninsurance.as rcquiEdbySection3T0OofthchborCodc,fortlEfrrfomwe()f <br />the work lbr which this pernrit is issued. My workcrs' conpensatien ifusurilce cffiicr iud frclicy numbca oe: <br />Policy <br />_l ccnify that in llrc lrrfinrnanc!'of thc work for whiclr this pcrnlit is issued, I shall not cnrploy ury pcrson i[ my manncr <br />m as to bccorrc subjcct to thc workt'rs' conpcnsation laws of Califomia. and ag@ thal if I stnuld becom subjccl to thc <br />uorkcrs' conpen\ation provisioN of Section 3700 of the Labor Codc, I sltsll, fonhwith conply with tho$ provisions.. <br />WARNING: Failurc to rccurc worlers'co,npcnsltion covcrage is unlawful, and shall subj.ct an cmploycr to Fimindl pcmlti* and <br />civil lirEs up to onc hurdrcd thousand dollars ($I0O,UJ0). in additioD to the cosl of co[rJE[etion, dmugcs s provided for thr <br />Sectior J076 ofthc tltnr Codc, intcres( md altorNy's [es. <br />LICENSED CONTRACTOR <br />I)I]CLARA'I]ON <br />I hcrcby afftrnr undcr lrcnalty of perjury that I anr licurd under pruvision of Chaptcr 9 (corlnrncing wilh Section 7000) of Division 3 <br />of lhc tiusiness ald l,rcfcssions Code. and trrv license is in full lbrcc und elfect. <br />Liccnsc Class:-Licensc Numbar: <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby allirm undcr Fnally ofpcrjury that thcrc is a construction lcnding agcrcy tor thc pcrformance ofthc work ttlr which this pcrrnit is <br />issucd (Scc. 3097. Civ. C.). <br />lf,nder's Nanrc. <br />kndcr's Address: <br />APPI,ICANT DECI,ARATION <br />I hrchy dIl'ilmundcr |tnalty of pcrjury onc oflhc following decl{ati{)ns: <br />Dcnx)lilion Pcrnrils-Asbcskrs Notification Fcdcral Rc8uluions (Tillc 40. Pd6) <br />_Rcquircd trtrcr of Notification <br />_l ccrliiy thal lhc l'cdcralrcgulntions rcge(ling asbcst)s rcrnovaldc nol applicablc to this projcct. <br />_l cc(ify tlHt I luvc rcad ttus application url state llut lhc above inlbrnution i5 corcct. I agre to conrply wilh all Cily and County <br />ordinanccs and Statc hws rclding b boildinB constructiotr ard hercby authorizc rcprcsotativcs ofthis City ild County to emo upon rhc <br />abovc Ncntioned pft)peny lor inspcction purF)ses, <br />AppliceDt or Agot SiSElur: Date:_ <br />Pcmiae namc (pnnl,: <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Signs (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 (Ftough) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinqs (T-Bar Rouqh) <br />lvleter Release <br />Rouqh <br />Service l\tleter <br />FINAL /!-Zs-72 ?-/detz 49 <br />Notes, Remarks, Etc <br />Fle <br />Canrer: