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ELECTRICAL-INSPECTOR BECORD <br />Bev. 08-07-201 5 <br />APPROVALS DATE ID/SIG.COMMENTS OWNTiR BI.JILI)ER I)I.),CARATIoN <br />I hercby affrnl undcr pcnrhy of pcrjury that I am excnrpt frcnr the Conlraclos Liccnsc law for thc following cdgn (5(.703 1.5 <br />llusincss and Prolcssion Codc): Any City or Counly which rcquircs a pcrrnil to construct. altcr, irnprovc. demlish or rcpair eny <br />structurc, pri()r to ils issuance. ulso requires thc applicail lbr such penrit to file a si8ned slaterrnt lhat lE or shc h licc[Ed pursdl <br />to (hc previsions of ttr Contracbr's l,iccnscd liw (Chaptcr 9, Commcncing with Scction 7uru ol Division 3 ol'thc Business and <br />Proles$ionsC(xle,orlhatltorsheiseremplthereftunraDdthebasisfottlEallegedexetuption. AnyviolationofseclionT0ll.5byany <br />npplicxnt for a pernril subjects the applicanl to a civil pennhy of nol norc thun Ilve hundted dollurs ($500). <br />_1. a\ owncr ol-tlt profEnv. or my crnplovccs wilh wa8cs as thcir solc compnsation, will d() thc work and thc strctue is not <br />irilcrrlcd o, oflered for Mlc (Sec.7tE4. Business anrl Prcfcssions Cqlei Tbc Conlraclor's Liccns law des not apply lo fln ownct of <br />the prcFny who builds or inproves therqnl urd who does such trt)rk hinself or lErself or lhrough his or her own enlployees, <br />pro\ idcd rhat such irnprovr'mnts uc mt inrcndcd or olfcrcd Ior sL'. Il. howcvcr. 0rc tiliHing or improvcmnt is sld within onc yta <br />ofconrplelior, tlt Owner Builder will havc the burd.n ofpmvin8 that he or she did not buikl or iffpNvc thc pmpsty for the purF)s of <br />sb). <br />_1. rs owncr of the prolEfly, an exclusi\ely contracting with liccn*d contracbrs to conslrucl thc prcjcct (Se. 7Og. Busincss <br />au-l Pnrlisiil Codc: The Contrack)r's LiceDse Law d(Es not apply to an ownet of profB(y wk) builds or improves lhercon. <br />and who cont'acls for such prt,iccts with a Conlractor(s) liccn*d pursuMl b thc Conkaclor's Liccnsc Larv). <br />-l <br />anleremlx under Section-, B. & P.C. tbr t[is reasoo. <br />]YIT86EB5J;9I4T[NSAJJ9N <br />DECLARATION <br />I lrcreby afllrnr undcr pcnalty ofpcrjury one ofthc l'ollowing decldations: <br />_IhavcandwillnrainlahaCeflificatcofcoDsenttoSelf-lnsurcforworkqs'compcnsation,as povidcdforhyScctionJT00ofthc <br />libor Codc, to, thc pqfoilmftc ofthc work for which lhc pcrnil is issued. <br />_l havc aud will nruintain workeB'insurance. as by Scclion 37m ofthc kbor Code, for thc prfornurre of <br />:cmier axl lblicy nun$cr de:tlrc work for which rhis pcrrit ls <br />(a o <br />Policy <br />_l ccf ify rhal in thc lrrforn)ucc o[thc work for which this pcrnil is issucd, I shall not cnrploy any lErson in my milncr <br />so as to bcconrc subjcct to thc workers'conrpcnsation laws ofCalifornia, and agrcc thal ifl should bccorrc subjccl to thc <br />uori<crs' corrrlrnsation prcvisions ofSection 370O ofthe tabor Code, I shall, fonhwith corrply with tho* prcvisions.. <br />WARNING: Failurc lo sccure workers'coDrpensation covcrag. is unlawful, and shall subject an cmploycr to dminal pcnnltis rnd <br />itr the cosl of eompetrsrlion. danuges as providcd for lhe <br />I hereby affirtrr undc'r lEnrlty of pcrjury that I anr licened 9 (coniln ocilg with Secrion 7000) of Divi,tiotr 3 <br />of thc Business and Codc. arx, my liccns is in full fore 0rxl cffccl. <br />€-7€ <br />)q <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby alllrm undcr pcnalty ot pcrjury rhd lherc is a construction lcndinS agcrcy for the Islbrmmc of thc work lor which lhis pcrmit is <br />issued (Scc. 3097. Civ. C.). <br />Lender's NanE: <br />@EEE!&I!gN <br />I hrcby ilI'irmundcr pcnalty of pcrjury onc ofthc following dccluations: <br />Dcnxrlirion Pcrnits-Astf,.slos N()tificati()n Fcticral RcSulations (Title 40, Pd6) <br />_Rcquircd lrttcr of Notification <br />_t ccnily that thc I'cdcral rc8ulalions rcgtrding asbcslos rcmovrl ilc not applicablc to lhis plotct. <br />6l ccniti rtrur I luvc rcad this application i{xl statc thal lhc abovc infbrnhlion is corect. I sgre to conDly with all Cily add CouDty <br />,rcpre$nklivcs ofthis City ild County to cntq uFrn UEordinmccs and Statc bws rclating to building <br />above nlentioned pmperly for inspcction <br />Al)l)li(atrt or Agrtrt <br />l'cmrilcc namc t> <br />hcrcby au(lnrizc <br />^,",V/7f ;n <br />Site-Work <br />Underqround <br />Pole Bases <br />Light 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 <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 />ltleter Release <br />Rouqh <br />Service [Vleter /^\ <br />FINAL L-lo-zt v.rL)6.1 <br />Notes, Remarks, Etc. <br />civil fincs up to otrc <br />[rnd.r'* A,ldrcss: