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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUII,DER DI]I,CARATION <br />I hercby aflrnr unrler pcnalty of pcrjury that I an cxenrpt fronl lhc Con(ractoN' Liccnsc l:w for the following rcasn (Scc.7031.5 <br />Busincss arxl Profcssion Codc): Any City or Couily which rcquircs a lEmil to construct, altcr, irnprovc, dcmlish or rcfat sny <br />structurc, prior to ils issuance. aLso rcquires lhc applicilil tbr such pcmit to filc a si8ncd slalercnl lhat lE or shc is licatrsd pursuant <br />to thc prcvisions oftht'Contrelor's l-iccnscd lrw (Chaptcr 9. Commencing wilh Scction 7fi)0 ofDivision 3 o[thc Busincss md <br />ProfessionsCode)orthatheorsheisexen4rttherefromandtlEbosislbrtheallegedercnrptiol. AryviolationofsectionT03l.5byaDy <br />applicantforup.nnitsubjctsth€ applicnntloacivilpenaltyofnolrmrcthanllvchundr.ddolla,s($5m). <br />_1. a\ owncr of lhc foFrcny. or my crnployccs with waScs as their slc compcnsdion, will do thc work aid thc stMm is ml <br />iucrxlcd or offercd for Mlc (Se.7(X4. Busincss and Prcfassions Codc: Thc Contraclot's Liccns Law docs not apply to an owncr of <br />the pmFEdy wlrc hoilds or irproves ther6)E aryl wln d@s such wo* himself or ltr*lf or through his or her own cn{rloyecs, <br />providcd that such impr)vcrrnts {c m! iilcndcd or olfercd lbr Mh. Il. howcvq, 0E building or irnpmvcmnt is $ld within one ]rd <br />ofconplclion, thc Owrer Buildcr will have th€ bordcn ofpmvin8 thd h. or shc did rct buill or irpDvc thc pmpa'ty for thc purporc of <br />sle). <br />_I. ns owncr of the prcpeny, am cxclusi\ely contracling wilh liceMd contraclors to conslrud lhe prcjcct (Scc. 70,14, Busines{ <br />and Prclbssifl Code: The Contracbr's License Law des not apply b an owner of prope(y who huilds or improvcs thcreon. <br />and who contEcts for such p(E'cls with a Conlracbr(s) liccnscd pursu&l to tlrc Conuacto!'s Liccosc hw). <br />-Ianlexen]ptutrdersccti()[-.B.&P.C.lilrtlrisreason.l)rte:_ <br />WORKERS'COMPENSATTON <br />DECLARATION <br />I hercby aflirm undcr pcnally ofpcrjury onc oflhc tbllowing dccl4dions: <br />_l have imd will nrairilah a Ceniticate of Consent k) Self lnsure fot workcrs' compcnsation, as prcvirlcd for by Section 3T00 of thc <br />hbor Codc, for thc Jtcrfoflumc oI lhe work lor which lhc pcrmil is issucd. <br />_l havc arrd will nuintnin w()rkers'conlpensaliur insurarce. as rcquired by Seclion 3?00 oflhe bbor Codc, for the po{omErEe of <br />thc work rhis is issucd. Mv wurlrcrs' comrcosstion iEurucc cmicr arxl mlicv numhcr ue:A/ofrn,o( InfttQtr\ce- Ca <br />I'olicy <br />_l cc(ify that in thc lL.ilununcc of lhc work for whiclr this pcrmil is issucd, I shall not cnrploy aily lrcrson in any manncr <br />s as to bccor* subjcct to thc workcrs'conpcnsation laws ofcalifomia. and agrcc that ifl slFuld bccorN subjcct to thc <br />workers' cotrlpen\alion l)rcvisions of SectioD .1700 of the Lat{r Code, I $ball, fo(hwilh conlply whh lhos provisions.. <br />WARNING: Failure lo scure workers' <br />civil tines up to ()nc hundred thousand <br />cornpensulion coverage <br />dollnrs (Sl00,U)0). trr <br />and dk{tuy's lccs <br />is unlawful. and shall subjcct m cmployer to oiminal pcn1ltics <br />ion, dmugcs c nrovitf: for <br />rnd <br />llEiddilinr !)cost of compcrtsal <br />Scction 3076 Codc. intcrcst <br />( <br />DDCI,ARATION <br />I hcrcby affrrn undcr pnalty of pcrjury thal I anr liccn*d untlcr prcvision ofchsptcr 9 (conmEncing with Srction 7000) of Division 3 <br />of thc Bosincsr and Pmfessions Codc. srd mv liccn* is in full for€ uxl cffccl. <br />LiceDsc 1 a6 <br />Do <br />W <br />I hcrcby allirm undcr pt'nalty ol pcr_iury lhfft thcrc is a construction lcnding agcncy for thc pcrl'ormancc ofthc work lbr which this pcrmit is <br />issued (Sec. 1097. Civ. C.). <br />l.en,Jer's Narne. _ <br />lrnder's Address: <br />APPI,ICANT DECI,ARATION <br />I hrcby irflirnr undcr prnalty of pcr.iury onc of thc following drcluations: <br />DcnFlilion Pcrnits-Asltsk)s Notification Fcdcral RcEulations (Tillc 40, Pm6) <br />_Rcquircd l.llcr of Notilication <br />_l cdily th{ lhc fcdcral rcgulalions rcBtrdin8 ertrcsl)s rcmlal trc ret applicablc to this prejel. <br />($ ."nify rt,ur I luvc rcad this application and stale lhal lhc ah)vc informlrcn i <br />ordinanccs and Statc Laws rclaling to building construction, and hcrcby authorize <br />is corcct. I agre to @nrply qith all City ald County <br />reprercntativcs ofthis Cily md County to enter upon thc <br />*.,,3/7/*tabovc rrcntioned prcpeny fot in$pcc(ion <br />Appli(ant or Agmt <br />Pcmrilcc nanrc <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildins <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 />Ceilings (Hard & Soffit Rough <br />Ceilings (T-Bar Rough) <br />lt/eter Release <br />Rouqh <br />Service lMeter /n I <br />F!NAL ln-lo.7a b,tLlr.) <br />Notes Remarks Etc. <br />Rev.08-07-2015 <br />(