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ELECTRICAL-INSPECTOR RECORD I APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARA'I ION I hereby amrm under poalty of pcrjury lhat I m cxempt from the Contractors' l,iceNe Law for the following recon (Sec.703 1.5 Businss md Profdsion Code): Any C'ity or County which require a Fmit to constnrct. alt6, irilprove. dcmolish or rcpair any structue. grior to its isumce. also rcquirB thc applicant for such pemt to file a signed staternot lhal he or she is lictrsed pursuanl lo the provisions of lhe Contractor's Licenscd Iaw (Chapter s. Commencing wilh Section 7000 of Division 3 of the Business and ProfesionsCodc)orthatheorsheiseremptthtrefromandtheb6isfortheallegederanplion. AtryviolalionofsetionT0ll.5byany applicartforapennitsubj(tsthe applicanttoacivilpenahyofnotmorelhilfivehundreddollds($500). I. ro orvno of the propeny, or my employs with wags s their sle comptralion, will do the wo.k md lhe structue is not intoded or offered for mle (Se.7044, Busins md Profssions Code: The Contractor's l,icense Law do6 not apply to an owner of theprupcrty whobuildsorin4rrovelhsmn.mdwhodo6suchworkhirnselforherselforthroughhisorherowncmployees. provided that such itnpovqnols tre nol intaded or offqed for sle. If, horvevs. the building or improvonenl is pld rvithin one veir ofconrplaion. the Owner Buildq s,ill have lhe hrd6 ofproving thal he or she did not build or improve thc pmFHy for the purloseof sle). _1. m orvno ofthe profErty. ail exclusively contracting wilh licmscd contractors lo construct the proj(t (Scc. 7014. Busin*s and Pmfessbn (irde: The Contraclor's License [,arv doe nol apply to an owner ofpropeny rvho builds or improves thereon. and lvho conlrads for such projects rvilh a Contracto(s) licenscd pursuant lo the Conlraclor's License Law). _l an exempt under Strlion B. & P.('. for this re6on. Ihle:_ Osner: WORKERS' COIII PENSATION DECLARATION I hereby affirm undr penalty ofpujury one ofthe follorving <leclarations: _l havc md will maintaio a Cenificatc of CoNent lo Sclf-lNure for worktrs' compeGation, 6 provid€d for by Sslion 3700 of the Labor Codc. for lhe psfommcc of the work for which the pemit is issued. _I have od will maintain works compeNation insurancc. 6 required by S(tbn .1700 of lhe tabor Code. for the pEfotrnmce of the rvork for *hich this p€nnit is isuol. My work6' compcnslion iGuroce cuic md policy numbo re: Caricr: Policy Numbq:-lrxpir cs: -l ccrlify that in the psformance of lhc rvork for rvhich this psmit is issued. I shall not employ any p€6on in any milntr so m to becomc subjel to the work6s'compenstion laws ofCalifomia, md agre that ifl should become subjat to the workm' compcnsation prcvisiore of Srtion -i700 of the Labor Codc I shall. forlhrvith comply with lhos prcvisions.. WARNIN(j: lrailurc to wure workos'cornpmsalion coveragc is unlarvful, and shall subjcct an onployr to siminal poraltiB and civil finesuptoonehundredthousanddollars($100.000).inadditiontothecostofcompensation,damagesasprovidedftrrthe Seclion 3076 ofthe Labor Code. interol and altomey's fe6. LICENSED CONTRACTOR DECI.ARATTON I hoeby afl'irm undr penalty of pfrjury lhal I m liccnsl unds provision of Chapts 9 (commocing with Scction 7000) of Dirision l of the Businss md ProfesioE Codc. ild mv licmc is in full force od effmt. License Class: Dale: t-iccnse Number: Contractor: CONSTRUCTION LENDINC AGENCY I hereby allirm undo pmalty of pgjury that thtre is a construction lending agency for th€ pqfommce of the work for rvhich this pmnit is issued (Se. -1097. Civ. C.). Lends s Narne: - Lmd6 s ddrs: APPLICANT DECLARATTON I hseby allinn undq penalty ofpojury one ofthe following decldations: Demolition Pmnits-Asbestos Notification Fedsal Regulations ('l itle 40. Part6) Required lf,lls of Nolificalion _l ce{ify that the fedsal regulatioN rcgading rbestos rmoralue not applicable to lhis prcjec1. _l certify thal I have r€ad this application ild stale thal lhe ah)ve infonnation is coret. I agre to comply rvith all City and County ordinancs and Stalc Laws relating to buildrng construclion. md hqeby authorDe reprseilativs ofthis City dd County to qts upon the above rnstioned propeny for inspstion purpos6. Applic{trt or Agflt Signalure:Date: Pemite nxmc (print): Site-Work Underground Pole Bases Light Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Building Under Slab / Floor Bondinq / Groundinq / UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouqh Ceilings (T-Bar Rough) Meter Release Rough Service Meter FINAL 7-7f-?oto J;,tcl-a a-n Notes, Remarks, Etc. Dsae: