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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDI:R DEL(]ARA'I'ION <br />Iherebyallirmunderpenaltyofpe{urylhatIanexenrptfromtheConlraclors l,icenseLarvforthefollorvirgre6on(Sec.703lr5 <br />Busin6s md Profession Code): Any City or Couily Nhich requirc a ;mnit to construcl. alto. irnprrrle. donolish or rcpair my <br />strudure. prior to its issumcc. also require the applicanl for such permil to file a signed statemenl lhat he or she is licensed pursuant <br />to the provisions o[the Contraclor's Licensed [,aw (Chapter 9. (i)mmencing rvith Section 7000 ofDivision 3 oflhe Busine$ and <br />ProfsionsCodc)orlhatheorsheiserenrpllhtrerio,nandthebasisfortheallegedexenplion. Any\iolalionofSationT0.ll.5byany <br />applicantforapennitsubjststhe applicanttoacivilpenallyofnolmorethanfivehtrndreddollars($500). <br />I. 6 owner of lhe proFny. or nry employG rvith wags o their wle compeNalion. \rill do the work md lhe stnrdue is nd <br />intmded or offcred for $lc (S(.7M4. Busines and Prcfmsions Code: 'l he Contractors Licmse Lorv does not apply to an owns of <br />lheprcpeny uhobuil&orimprovsthqon.mdwhodoesuchwrrrkhimselforherselforthnrughhisorherorvnenrployew. <br />providedlhalsuch impmvqnots[enotinlmrledoroflLrqllirrsle.lf.howcvq.thetnrildingorirnprovementissoldrvilhinone]w <br />ofcotnphion. the Owmo Buildtr will have the burdo ofproving that he or shc did not build or improvc the p()pqly for the puqnsof <br />sle). <br />-1. <br />a orvno of the prolmy, m exclusilely contracting \r ith Iicensed contractonlo conslrucl the pr(li(t (sec. 7014, Bwins <br />md hofcsionCode:TheContraclor'sl-icenseLawdo6nolapplyloanoN'nqofpropayrrhobuildsorimproveslhq@n. <br />and rvho contmcts for such prcjets with a Conlractor(s) licensed pursuant to lhe Contmclor's License Law). <br />-l <br />an exqnpt undq S{tion-. B. & P.C. for lhis re6on. <br />Dsle:_ Owner:__ <br />WORKI]RS' COI\IPENSA'I'ION <br />DECLARATION <br />I hacby affrm under pqralty ofpqjury one ofthc follorving dclarations: <br />I have md rvill rnaintain a Cffillcate ofConsmt to Self-lnsurc for rvorkos'conrpensation. c provided for by Section 3700 ofthc <br />Labor Code for the perfomance of the rvork for which the pfinil is i$ucd. <br />-lhaveandrvill rnainlainworkers'compensalioninsumnce.d requiredbySrtion.lT00oftheLahorCode.forthcpqfummceof <br />the u,ork for rvhich this pennit is issued. My rvorkm' compensalion insurance canio md gxrlicy number oe: <br />Carrier: <br />I\rlicy Nunrbcr:Iirpir cs: <br />I cenify that in the perftrrmance ofthe work for which lhis permil is issued. I shall nol eDploy any person in aly manner <br />so ro to become subjecl to lhe ['orkss' compensal ion lavs of Calihrmia. and agre that if I should lrecome suhjrct to thc <br />\rork6' compeosalion provisions of Salion 1700 of the l,atror Codc. I shall. forlh\ ith coilrpl]- \\ ith tlrcs frcvishns.. <br />WARNINC: Failute to sure rvorkm'cornpasalion co\'(age is unlarvful. and shall subjrct an onploy.o tn oirninal penaltie md <br />civil finesuptoonehundrcdthousanddollars($100.000).inaddiliontolhecostofcornpensalion,darnagesasprovidcdforthe <br />Seclion 11076 ofthe Labor Code. intdBt 6nd altomev's fees. <br />LICENSED CON'IRACI'OR <br />DECLARATION <br />I hereby affinn undo penahy of perjury thal I m licensal under p(rvision ofChapto 9 (commencing rvilh Section 7000) of Division 3 <br />of the Busines md Profsions Code. md rnv licme is in full force md eff(1. <br />Lice6e Class; <br />Daae:_ <br />License Numbor _ <br />( onlrnc(or: <br />CONS'IRU(:'I'ION LENDING AGENCY <br />I haeby aflirm undo penaly of pfrjury thal th6e is a construction lcnding agmcy for the pofonnancc ofthe $ork for s'hich this pornil b <br />issued (S(. 3097. Civ. C.). <br />Lcnder's Name: _ <br />Lstder's Ad&esr <br />-APPLICANT DECLARA'I'ION <br />I hotby alfrm under penalty of p6jury one ofthe following delrations: <br />Demolition P6mils-Asbcstos Nolification Fedsal Regularions ( l itlc 40. Pd6) <br />Requfed Lcllq of Notificalion <br />_l certify thal thc fedoal regulations rcSuding dbeslos removal are not applicable lo lhis prcjecl. <br />I cqtify that I have read this application dd stalc thst thc atnvc infonnation is cor(t. I agrc to comply wilh all Cily and County <br />ordinancs and Stale Larvs rclating to buildinB constrnction. <br />ffi;-^-ffi:.:",:ff'z%_ <br />Pemire nnme (prrn u,&jn r / > > <br />reprsef,tal iv6 of this ('ity and Counly to ents upon the <br />Drte: t <br />and hereby <br />z-/f-z <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildins <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 (Rouqh) <br />Ceilings (Hard & Soffit Rouqh <br />Ceilings (T-Bar Rough) <br />Meter Release <br />Rough <br />Service Meter {-- r) <br />FINAL Ub/1t6,Kt )na,l,t hc/ <br />Notes, Remarks, Etc./ a\t <br />na n7 aAlAt:_r