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ELECTRICAL.INSPECTOR RECORD <br />hlspealir )n <br />APPROVALS DATE ID/SIG.COMMENTS ( h{ncr-Builder Dcclaration <br />IherebyaffrrnrunderpenaltyofperlurythatIafiexenrplformlhe('ontraclors l,icenseLawforthefollowingreason(sec.701L5Busind,s <br />and Profession Code): Any Cily or County which requircs a pcrmit to construct. alter. irnprolc. dcmolish or rcpair any slructurc, prior to its <br />issuance.alsorequircslheapplicantforsuchpcrmittofilcasigncdst6lemcnt thath.orsheislicensed plrsuanltolhcprol,isionsofthe <br />Conlraclor's Licensed l-sw (Chapter g, Conrmencing with S6tion 700O ofDivisron J ofthe Businss and Professions Code) or lhat hc ot <br />she is exernpt lhercllom and thc basis for lhe allcged excmption .Any viol0lion of Section 703 I .5 by any applicant for a pennit subjccts lhe <br />applicanl to s civil pcnally of not more than fivc hundred dolhN ($500). <br />l. as owner oflhe pmpeny. or my employecs wilh wages as thcir solc compensalion. will do thc lvork and lhe struclurc is not inlendcd <br />orofTeredforsale(SecT044,BusinessandProfcssionsCode The('ontractor'sl,icenseLawdoesnotapplytoanownerofthepropeny <br />who builds or irnproves lhcreon. and who does such work himselfor herselfor lhrough his or her orvn c,nployccs. provided lhat such <br />irnprovemenls are not intended oroffared for salc. lf. howevcr. thc building or irnproternent is sold wilhin one ycar ofcomplarion. lhe <br />Owner-Bililder will have thc hilrden of provinE lhat he or shc not build or improvc for lhe purpose ofsalc). <br />_ l. as owner oflhe propedy. am e\clusively contracling wilh liccnsed contmctors lo construct thc fojecl ( Scc. 7044. Busiress aild <br />Profession ('ode: I he (-<)ntraclor's l-rcense kw does not apply lo an owner of propedy who huilds or inproves thereon , and who <br />conlracls for such proiects wilh a ('ontraclor(s) lrcensed pursuant lo lhe Conlrackrr's l,icense l-aw ) <br />I arn e\crnpl undcr Scction B. & l).C. for this rcason <br />l)alc:()s,ner: <br />WORKERS COMPENSATIoN DECLARATION <br />I herchl- alTirrn under penalty ofperjury onc ofthe folhrving dcclarations: <br />_l have and will maintain a Cenilicatc of Conscnl to Self-lnsure for workers compenmlion. as provided for by Section tl?oo of tlrc <br />Irbor Code. for lhe pcrfonnance ofthe work for rvhich the pcrmit is issucd. <br />5(har" und will nnrnlarn workers conlpensatrcn insurance. as required hy Section l?00 o <br />&orkfor*hichthispermitisissued lvtyworkers comp€nsationinsoranceceTier.ndF,olicy <br />c",i.., 7{ fvt1Q, r L<O 4 Ar.,, q.,rle.2'\feo <br />eoti.yH,,nt.,, OI-1[r' 3f,* 9L- Erpircs: <br />('l his seclion need not bc complcted ifthe permit is for (he hundred dollars {$l 001 or lcss) <br />fthe Lahor ('ode. l'or the perfornrance oflhc <br />numher are <br />t[[ru <br />I cenify thal in the pcrformance oflhe work for which this perrnit is issued. I shall not employ any person in any manner so as lo <br />hecame suhiect lo the workers conrpensalion laws ofCalifornia. and aSree lhal ifl should lrcconre subject to the workers' <br />compcnsation prorisions ofSecti<rn.1700 ofthe Labor (bde. I shall,fonh* ith cornolv rvith lhose Drorisionstll.-tJI).te:trlutn ( <br />llARNlN(; Failure to secure worlers rs unla*ful. and shall subjccl an employcr to crirninal penalties and ci!il <br />fines up to one hundred lhoussnd dollars ($100.000). <br />the lrhor ( ode. intercst and attornev s feet <br />the cost ofconrpensation. danrages as providcd for lhe Section :1076 of <br />LICENSED CON'TRA('TORS DECLARATION <br />I hercby amrm under penahy ofperiury lhal I am licenscd under provision ofChapler I (commcncirll with Section 7000) ofDivision.l of <br />the Business and Professions ('ode. and mv licensc is in full force and effect <br />I.i".n..ct"r.,Q / -15,* alztltF <br />951_-t ?r <br />(i)nlractor: <br />I herchy amrm unds fEnahy ofperiury lhat thcrc is a <br />issilcd (Scc. 3097. Civ. C.). <br />l,ender's Nanre <br />lcnding aSency for the perfonnance oIthe work fur which this permit is <br />l-ender's Address <br />APPLICANT'S DECLARA'I'ION <br />[)enx)lilioa Pcrilrils-Asbcstos Nolification Fedcral R.Bulntions (Title 40. P.n 6) <br />Rcquired Lelter of Notifi cation <br />I ceflify lhal lhe fedcral regulations r.Ssrdinll asb6tos rcmoval arc nol lpplic&hle h this projccl <br />)lcenitv <br />ordinances r <br />that I have rcad lhis application and slate that the above information is conect. I agree lo comply Nilh all fity and Counly <br />and State Lalvs rclaling lo buikling construction. and hcrcby author izc rcprcsentaliles ofthis Cily aod Counly lo cnter ulon lhc <br />sbovc menlioned inspection purposcs. <br />Applicant or agent sig. <br />Permiltee nanre (priilt):Jffr o <br />,*",J4zLLh <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Transformers <br />Torquing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soffit Rough <br />Ceilings (T-Bar Rough) <br />Meter Release <br />Rough <br />Service Meter <br />FINAL u/n//6 =Hg etrnla I t <br />Notes, Remarks, Etc.t vv \UI