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ELECTRICAL-!NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS oWNER BUILDER DELCARATION <br />I hcrchy aflirn undcr pcnalty ol pcrjury thal I Mr excmpl lionr lhc Conlrack)rs' l-iccnsc ljw tbr the folk)wing rcason (Scc.7oll.5 <br />Busincss and Proltssion Codc): Any City or County which rcquircs a Jrcrmil to construcl. ahcr. improvc, dcmlish or rcpair any <br />structurc. pri()r to its issuancc. also rcquires lhc applicant for such lErmil lo lilc a signcd statcmnl thal hc or shc is liccnscd pursuant <br />t) thc provisions of thc Contrrctor's Liccnscd l-aw (Chaptcr 9. Cornmcncing wilh Scclion 7(XD of tjivision :l of thc Business rnd <br />ProlcssionsCodc)orlhathcorshciscxemJ,tthcrclromandlhcblsislbrthcallcgcdexcmption. AnyviolationofScclionT0Sl.5byaDy <br />applicantlbrapcrmitsubjcclslhc applicanlnlacivilpcnahyolDolmorclhanfivchundrcddollflrs(S5U)). <br />-1. <br />as owncr of thc pmlrcny. or my employccs with wages as lhcir solc compcnsat ion. will do thc work and lhc stmlm is not <br />intcndcd orol-hrcdforsalc(Ss.T044,BusincssandProttssionsC-odc:ThcConlractor'sLiccnscLlwdocsnolapplytoanowncrof <br />lhcpropcily whobuildsorhnprovcsthermn.mdwhodoessuchworkhimsclforhcrselforthroughhisorhcrowncnrployccs. <br />providcd that such imprevcnEnts arc ml inlcfrlcd or offcul lirr ulc. lf. howcvcr. lhc buikling or improvctrEnl is s)ld within onc yce <br />ofconrplction. lhc Owncr Buiklcr will havc IEL burdcn of proving lhat hc or shc did not build or inprow lhc pmfEny tbr lhc purlx)r of <br />ulc). <br />I. ils owncr ol lhc prol)cny. ilnr cxclusivcly conlrrcl ing wilh liccnscd co[trrclors k) conslrucl lhc projccl (Scc. 7(]14. Busincss <br />ilnd l)E)ll'\siolCodci'l'hcConlrrclor'sLiccnst'l-awdocsnrnapplyloanouncrofpropcrlywhohuildsoritrrprovcsthcrcotr. <br />anrl who conlracls lbr such frr()jccls with a Corilracto(\) Iiccn\cd pursurnl lo lhc Conlrrcl()r's Liccnsc l-nw). <br />-lrmexclnDtundcrsccti()n-.B.&P'C'rorlhisreason. <br />I )illr <br />- <br />O*ner: <br />IVoRKI.]RS' CoNIPtrNSA'I]oN <br />DFCI,ARATI()N <br />I hcrchy allirnr undcr lcnalty ol pcrjury onc ofthc l(,llowiDg dcchrrlions: <br />_l hdve and will nlainlain il C'cflilicalc ol Conscnl b Scl[lnsrrc lbr workcrs' corrpcnsalioD. as provided li)r hy Scclion -i7(X) of lhe <br />litDr Codc. lbr lhc pcrtbrmancc ofthc work for which thc pcrnril is issucd. <br />_l havc and will nrilinlain workcrs' conrpcnsali()D insurancc. us rcquircd hy Scction 3TU) olthc Labor Codc, lor thc pcrlbrnuncc of <br />thc work for which this pcrmit is issucd. My workcrs' comfcnsali([ insurrncc caricr and policy numbcr trc: <br />( <br />Policv Numbcr: Exotcs <br />_l ccnify that iD thc pcrli)rillilncc ol lhc work li,r which lhis pcrmil is issucd. I shall lol co]pby any pcrson in any illilnncr <br />so ils lo hcconr suhjcct lo thc workers'conlFn\ali(n laws olCalilbrnia. and ugrcc lhal if I ihould hccorE suh.icct lo lhc <br />workcrs'coilrpcDsati(nprovisionsofScctionST{X)ofthctihrrCodc.lshall.li)flhwilhconrply*ilhtho$prcvi\hns.. <br />WARNINC: Frihrc lo sccurc workcrs'coillpcnsnti()n covcrilgc is unldwlul. and shall suhjcct an cnrphrycr lo (Tinlirlrl 1tmltics and <br />civil lincs up lo onc hundrcd lhousand dollars (Sl(n.0(X)). in addition lo lhc cosl ofconrpcnsalion. datrugcs as providcd lhr thc <br />ItcsScction 3076 of r CA-L- <br />I hcrchy ufllrm undcr pcnalty of pcriury thflt I ant liccnrd undcr provision ofChaplcr 9 (connrrncing with Scclim 70tD) of Division 3 <br />ol thc Businc\s and Profcssions Codc. ard nty liccnsc is in lull Ii)rcc nnd clltcl. <br />l,iccnsc Class: <br />Drtei t c_(irnlrac(or: <br />C(INSTRUCTT(IN LENI'IN(] A(;ENCY <br />I hcrcby affirm undcr frenalty of pcrjury thal lherc is a conslruction lcnding agency frrr thc pcrli)rnuncc of lhc work for which lhis fErmil is <br />issucd (Sm. 3(xr7. Civ. C.). <br />Lcndcr's Nanrc: <br />I c'xlcr'\ A(hlrc\\: <br />APPLICANT DECLARATION <br />I lmrtysfiimundc. pcnalty of pcrjury onc of lhc following dcclarulions: <br />Dcnx)lilion Permits-Asbeslos Notillcation Fcdcrtrl Rcgulations (Title 40. Pail6) <br />-Rcquircd <br />lxtlcr of Notilicnlt)n <br />_l ccnili lhal lhc fcdcral regulatioDs rcguding dsbcslos rcrnoval arc nol rpplicrhlc lo lhis prcjccl. <br />-l <br />ccrtify th0l I havc read lhis applicalion and stxlc lhal agrcc k)comply with all City and County <br />his City and Counly to cnlcr llhn thcordinanccs and Statc Lrws relating to building <br />flbovc nrcntioncd propcrty for <br />Appliront or AgeDt Signature: <br />f'ernrilec nanre (pritr O, L 4-r.y <br />ivcs ol l <br />Da,e: 2lta* <br />-_|-7- <br />Site-Work <br />Underoround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bondino / Groundinq / 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 />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinos (T-Bar Rouqh) <br />l\Ieter Release <br />Rough <br />Service Meter <br />FINAL <br />Notes, Remarks, Etc. <br />4O\l)alr: