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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/S!G.COMMENTS oWNI]R III.]II,DT]R DI.)-CARATION <br />t hcrcby affirnr under pcnalty of Frjury that I atrl ercnli frunr the (lontractoN License bw for the followilg rcaen (Sec.70ll.5 <br />Buslncss aftl l,rolcssi()n C()dc): Any Cit)'or Cr)uily which rcquircs a l--flnit h construct, altcr. irnprovc. dcmolish or rclair any <br />structure,pri(trk)irs i\surtre.nlsorequirestheapplicanlforsuchEnlittrfihasigrrcdslulenEnt tlMtheorsheislicensd Iursuant <br />to lh! pmvisions ol'llr Conlrnclor's l,iccnscd llw (ChaItcr 9. Comrncncing wilh Scclion 7(Xn ol l)ivision .] ol'thc lrusincss and <br />ProfessionsC(xle)orrhallEorsh!,isereDrPttherelionraildtlEbasistortl)eallegedexenlpttm. Anyviolaliolr)fseclionT0ll.5byany <br />.pplicxnlforapcrDilsubjcctslhe npplicunltorcivilpeDnltvofnolrnorethanfivehundreddollars($5(X)). <br />_1. fls o*ncr ol thc. prol^-f,v. or rny crnployccs with wagcs as thcir $tr' compcnsation, will do thc work arx, thc stMlurc is fr{ <br />iilended or offercd for rdlc (Scc.?(M,I. Business and Pmfcssiuls Codc: TIK Contrilcrcr's Liccnsc bw d@s not apply to o owncr of <br />tlt ptr)Fny wlx) tNrlds or improves llErqn, aril wln d(Es suclr wr)rk himself or lEr*lf or through his or lEr own enrployees, <br />providcd thal such improvcrmnrs rc ilt intctolcd or olLrcd for $lc. ll, lmwcvcr th. buiHins or imprrvcrrcnt is mkl within onc yctr <br />ofcoil{rletfun. tlt Owrrcr Buikjer will lnvc ttrc burden olpnrvirrg thl lE or rhe did not boi[.] or imprcvc thc pft)fEny for tlE purposc of <br />$rh). <br />_1. $ ()wNr oI the lrlrpcrly, ilm cxclusirely contrurting with licensed contraclors to construcl tlrc prcJect (Sec. 7(X,1. Business <br />aml l,rollssiur Corle: The Cor[rilctor's l-iccnsc Law d(Es n(il apfly k) an owner ofpropcny who builds or inlproves llcre(ilr. <br />and who conlmcls lor such prr)i('cls wilh a Contrachr(s) liccn*-d pursuMl h (hh (:()nlrachr's Liccnsc hw). <br />-l <br />anr cxcnrpt urder Sectiou-. B. & P.C. l'ur this reason. <br />I)illt:- <br />TV('RKI:RS' COI\I PT:NSATION <br />DECLARATION <br />I hcrcby aflirm un(lcr pcnnlty of f)crjury (,nc oI lhc li'll()wire dccltrati(rls: <br />_l have iurJ will nuirilaiD il Ce(ilcatc ofConsent to Selt-lnsure f(rr workers'conrPensation, as pnrvirJcd for bySecti()n 3700 ofthe <br />lntx)r Codc, for thc pcrformancc oflhc work litr which lhc pcftnit i\ issucd. <br />Qt*afe ana wltt nruirlallr workem conllENalion irsuratrce. as requred hy Secli([ f700 of lhe tibor Cod., for lhe Frf()rDurNe of <br />thc work l()r wlrich lhis lrrnrit is issuad. My uorkcrs' conrl*nsation iDsurancc cuier uxl Jxrlicy nunftcr uc: <br />wa\c <br />tt/r/?ol1)l icy c <br />_l ccnify lhat ii thc lrrlir nrancc ()f thc work f()r whiclr thrs Nrnrit is issur'd. I shxll not cnrploy aoy 1*rsor in any nranncr <br />so as to bccorm subjt'cl u) thc workcrs' con[^-n$atiotr laws olCalilbrnia. aDd agrcc that if I slnuld tEcont subjccl to thc <br />workers ru4rnsationprorisionsoISection]7il)oftheLaborCbde,lslull,fonhwitltcorrplywilhtho*provisions.. <br />WARNING: l:aihrre lo rccure uorlers'cornlEDsrlion coveruge is unlawful. and shall subjcct nn employcr h crirnin{l fennllies rnd <br />civil fincsuproorchuildredth(,usatddollirs($100.m0).itaddiliurlolhecoslol'compeNaliur.darlagesasprovidedlbrthc <br />Scction 3{176 ('l lhc l-ahtr (ixlc. inlcrcsl atrd ['t'ru,,na1!14_a <br />I)E('I,AITA'I'I( }N <br />I hcrcby affirnr under |xtrnlly of lErjury thnt I anr licensd under pruvision of Chrpter 9 {cornnrncing with Scction 7000) of Division 3 <br />o[ the Busincss and Pmfessions ('od., ard nrv license is in full forcc rnd ellicl. <br />l-i(crse *d,,*,, q)?)(G <br />,"*,2 ^Z -r-i --'t-.4- <br />W <br />I hcrcby allirm undcr pcnalty oI pcrjury thnl thcrc is a conslruction lcnding agcrcy lor thc pcrlbflnarcc ofthc work lbr which this pcrmit i\ <br />issucd (Scc. l{)9?. Civ. C.). <br />l*nder's Nanre: <br />[andcr's Addrcssl <br />APPI,ICANT DECI,ARATION <br />I lmby affrnrundcr Fnalty of pcr.iury onc ol thc firlkrwing dccluations: <br />Dcnx)lition Pcrmits-Ashr'slos Ndificati()n Fcdcral RcSulalions (Titlc 40. Pm(, <br />_Rcquircd [.ttcr of Notificntt,n <br />_l ccnili lhal rhc ltrlcralrcgulations rcgudin8 asbcslos rcrmlal atc nol applicablc to this pr+d. <br />irnl arxl slrlc thrl llN ah,vc in,i,urali()n is crlrccl I uBrcc to conlply willl all Cily an(l (i)unty <br />nt cons[r(tion, rnd hcrcby trulhorizc ol this Cily and County to cntcr upon thc <br />rlxrr'e nrcrtionrd propcrty for <br />Appli(rnt or Agrtrl <br />l'cmrilcc neorc lpntrt <br />purlx)se\. <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safetv /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bondinq / 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 />Ceilinqs (T-Bar Rouqh) <br />lt/eter Release <br />Rouqh <br />Service lMeter <br />F!NAL r'7/r/Z ).4*/%/ <br />Notes, Remarks, Etc./Y '.\-/ <br />tAu^-t)-^.^ <br />**,? -?h-e o