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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE !D/SIG COMMENTS OWNIIR ttl.,ILDUR I)IILCARATION
<br />IhcrabyafftrDlutrderpenultyofperjurythatIaDcxemptfrunlthcContraclos Licen*[:wforthcfollowintrcaon(Scc.7031.5
<br />Busincss ard Prolcssion Codc): Any Cit!, or County which rcquircs a pcnnit to construct, altcr, irprovc, dcmrlish or rcpair any
<br />struclure, prbr m ils issuancc. xlso requifts thc applicuil for such fEf,ril to filc a sigrEd stalcrEnl ihat lE or shc is liccnscd pursant
<br />to thc pmvisions o[ thc Conractor's l,iccnscd law (Chaptcr 9. CommcncinS with Scction 7000 ol l)ivision 3 of thc Busincs and
<br />Profcs3ioNCode)orthatlEorsheiserenliltherefronrandtheb&sisfortlEullegedeiemptiul. AnyviolatiouofSetionT03l.5byany
<br />f,pplicilnt for a pennit subJccts thc npplicant to n civil penrlty of nol rrcre thrn five hundred dollars ($500).
<br />_1, &\ owncr ol tlE proltny. or my cmployccs wilh wagcs as thcir solc com[Ensation. will do thc work ard thc stMw is mt
<br />intc(lcd or offcrerl ftrr ule (Scc.7(X4. Busincss an(l Prcfcsskrrs Cule: Thc Contraclor's Licensc Law d@s not apply to an owrcr of
<br />the prupeay wlo builds or improws tlprlrnr, uxl wlm d(Es such work hinBelf or hrsell or tkough his or lBr owo en)ployecs.
<br />prolidcd that such irnprovcrmn(s arc mt inlcrdcd or ollk*d for sa.lc. Il. however, Ot building or irprovcmnt is sld wilhin onc ,rd
<br />ofcompLlior, tlE OwrEr Builder will hsve the burden ofpn)ving llut he or she did mt boill or irprcve thc pmpgty ftrr tIE puryne of
<br />snle).
<br />_1, u$ owner of the prupcny, dnr exclusivcly contracting with licen*d conlraclors lo conslruct llE projcct (Sec. 7(X4. Business
<br />arf,l hDtesskxlCode:TheContracktr'sLicenseLawd(EsnotapplytoanowDerofpropef,ywhobuildsorinprovesihereon.
<br />and who contracts for such projccts with a Contraclor(s) liccNcd puNuul to thc Contractor's Liccilse llw).
<br />_[ amexenrpt uilder Scc(ion_, B. & P.C. li,r thir reason.
<br />ffi
<br />I hereby affirm undcr lrcnalty of psjury onc of thc lbllowiDg declaratioN:
<br />_lhaveudwill nBinlairaCcfril'icat.ofConscnttoSclf-lnsurcfqworkes'compe[etion,ss Ff,ovidcdforbySation3T00ofthc
<br />Labor Codq for thc Frcrfoflffic of the work for which (he p6mit is issued.
<br />.6r urra nill nrarntarn workcn eonqrmati()n insurancc, as rcquiEd by Setion 3T00 of the tibor Codc, for lhc pcrfonrurcc of- lhc work for which this fErmil i3 issucd. My workos' mmpcnution imurmc cuicr urd fDlicy nuDber se:
<br />c*i..,( 5 hr fr-/^c/
<br />pori"yNuo",,, J 1Ll5t6cr e^pn"",7 o0 ttolzazo
<br />_l cciili that in (hc lrcrii)rnunc!'of lhc work ft)r which thls ltrnril is issucd, I shall not cn\)loy aoy Frson in any nranncr
<br />e as to bccoDE subjccl to lhc workcrs' cotrlpcnsnl ion laws of California. and agrcc that if I should bccorc subjcct to lhc
<br />workers'conrlEnsationprovisionsofSectionlT00oftheLatnrCodc,lshall,fonhwithcornplywiththosprovisions..
<br />WARNING: Failure to scurc workers'compcnsation coveagc is unhwful, and shall subject an
<br />civil Iincs up t<r onc lrundred thousand dollars ($100,000). in addilion to thc cost of
<br />Scction 3076 of thc btx)r Codc. intcrcsl md dklrncv s
<br />o*", .3- t0 - 20Zo
<br />I)ECI,ARATION
<br />I hcrcby affrnr undcr penalty of perjury that I anr liccn*rl undcr prcvision ofchaptcr 9 (conwncing with Scdbn 7000) of Division 3
<br />of thc Busircss and Prcfcssions Codc. arrl my liccns is in full fore and cffcct.
<br />Liccnsc
<br />Dale:
<br />(cz
<br />Nunrber:
<br />/107078[
<br />7t a -za z?
<br />CONSTRUCTION LENDING AGENCY
<br />I hcreby alliiln undcr tf,nahy ol pcrjury that thcrc is a construction lcndinS a8crcy for thc pcrlbrmarcc of the work lbr which lhis pcrmil is
<br />issued (Scc. 3097, Civ. C.).
<br />l-endcr's Nan'.:
<br />lrndc.'s AddGs:
<br />APPI,ICANT T'ECLARATION
<br />I heebyartrmrund* pcnally of pcrjuy onc of the folkrwiog d@ldstions:
<br />Dcmrlilion Permits-Asbcslos Notification Fcderal RcEulations (Titlc ,10, Pat6)
<br />_Rcqutcd trttcr of Nolilication
<br />_l ccaili that thc ltdcral rcgulations rcgudinS asbcstos rclfl)val trc not applicablc to this pmj(I.
<br />,{"n fy *url luvc rcild llus aplhcatiou drd strte that thc ahovc information is corcct. I agrec to comply wirh all City atrd County
<br />'ordinanccs and Starc Ltrus rclatint to b{ilding consmction, and hcrcby authorizc rcprcrenlativcs of this City and County to cnrq upon [E
<br />abovc mehlioncd pmpeny for
<br />Applirant or Agenl
<br />Pcmrilec nanrc
<br />^r".
<br />i4o -fu ?zt
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER //te/le1 l,.,jr, tzta 4u)
<br />Transformers I I I L
<br />Torqueinq
<br />Sub-Panels l/ltolgP -t -rg\ )
<br />Air Conditioners UJ
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soffit Rouqh
<br />Ceilinqs (T-Bar Rouqh)
<br />lt/eter Release
<br />Rough
<br />Service lrleter
<br />FINAL {@tZ-<i tt6-)
<br />Notes, Remarks, Etc.I Uo(€
<br />Bev.0B-07-2015
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