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ELECTRICAL.INSPECTOR RECORD <br />Rev.08-07-2015 <br />APPROVALS DATE !D/SIG COMMENTS OWNI',R BUILDI'R DEI,CARATION <br />I hcrcby affrnl u!iler pcnalty of lErjury thal I mr excnpl frum thc Contractos Licensc lrw for the followif,t ftaen (5(.70]1.5 <br />lJusincss and Profc$sbn Codc): Any City or Couily which rcqutes a pcrmit lo construct, altcr. irnprovc. dcmlish or rcpair my <br />structure. prior b its issuaNe. al\o requircs thc allplicail for such Fmril k) filc a sitrEd slatcmnl lhd lE or shc is liccrrrr.l puoant <br />lo rhc pmvisions of the Contractor's Liccnscd Ilw (Chaptc. 9. Commcncing with Section 7Ul0 of Division J of thc Busincss and <br />ProfessionsCode)ortlutltorsheisexerlpttherefromandtlrcbarisfortheallegedexeftptio[. AnyviolatioDofseclionT03l.5byany <br />applicantforafrnnitsubjcctsthc npplicrnttoacivilpcmltyo[nolmrcthanfivchundrcddollars($5U)). <br />_1. as owncr ol thc prol4-ny. or my crnployces with wagcs as lhcir $lc compensation, will do thc wo* ard thc strelwc is mt <br />iuoJed or offercd for tulc (Se.7l}l4. Busincss anr.l Pmfcssions Codci Thc Conlraclor's Liccnsc kw d@s not apply Io m owncr of <br />the pr4Eny who huilds or inrproves therdxl, urd who d(Es such work himself or l*rself or tlrough his or her own enployees, <br />providcd lhat such improvcrrcnts trc ml intcndcd or ollercd for sa.lc. Il howcvra OE buikling or improvcmnt is mld within onc yca <br />of conlpbtim, tlE Owrcr Buil-ler will have the burden of prcving thd h€ or shc rlid mt buill or inpmve th€ pNpqty for the purF)* of <br />s:rle). <br />_1, as owner ofthe prolEny, anr exclusivcly contracting with liccn*d contractoB to construct lhc pNject (Scc. 7(N4. Busincss <br />arrd PnrlissionCode:TheContracbr'sLicetrseLawdocsnotapplytoanownerofptopenywhobuildsorirDprovesthereotr. <br />and who contncts for \uch prolccls with a Contmct)(s) liceNd pursumt lo the Conuactor's Liccnsc kw). <br />_l antexempt utrder B &P(: l'orthis'?a\(nl. <br />WORKI'RS' COMPI]NSATION <br />DECLARATION <br />I hcreby allirm undcr pcnally of pcrjury onc ofthc li)llowing d@ldatiotrs: <br />_l have and will trEiilah a Ccditicale of Conscnl lo Self-lnsurc for workas' com;rcnsation, as prcvided for by S.clion 3700 of thc <br />lrbor Codc, tor thc pcrlornrmce ofthe work for which lhc pernit is issucd. <br />_l havc and will nraintrin w()rkcrs'by Salion 3700 oflhc l:bor Codc, for thc ;rrfomurec of <br />thc work which lhis rs irsucd.cmicr {d F)licy nunrbcr dc: <br />bnCe Ce <br />C /t/LrPolicy <br />_I cciiti that in thc Nrfornuncc of thc xrrk for which tlis pcrillil is issucd, I shall not cnrploy any lrcrsur in any ormncr <br />so as lo bcconr suhj.ct to lhc workc^' cotrlpcnsation laws of Califomia, and agrcc thal if I slnuld bccorrc $uhjcct to the <br />workers' coillpcDsation prcvisions of Sectiotr 3700 of rhe Labor Code, I slrall, fonhwith cplrply with thor provisioos.. <br />WARNING: Failure to secure workers'compensrlion covaragc is unlawful, and Nhall subjcct an crnployrr to fiminal pcnalties aild <br />eivil fines ul lo orc lNndred tlx)usand dollars ($100.0ur). in addition to llE lr*lAcompcNalion, <br />.* <br />dmugcs o plovided for thc <br />Iiltom'y's fccs. <br />LICENSED CONTRACTOR <br />I)ECI,ARATION <br />I hercby affrnr under pnalty of pcrjury lhnt I an) liccrltd under prcvision ofChaptcr <br />o[ lhc Busincss and Prefcssions Code. arxl my licensc is in full fore and cffccl. <br />9 (cotrmEncin8 with Scctbn 70U)) ofDivisiol 3 <br />License <br />re6 <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby allirm undcr pcnalry of pcrjury lhat thcrc is a conslruction lcnding agcncy for the pcrformancc ofthc work lbr which this pcrmit is <br />issued (Scc. 3097. Civ. C.). <br />[.nder's NanE: <br />lrnrler's Address: <br />APPI,ICANT DECI,ARATION <br />I hrcby aflmr undcr FnaIy ofpcrjury onc ofthe followiog dcclaratioos: <br />DcnDlition Pcrnrils-Astusk)s Nolificati()n Fcderal Reguhtbns (l itlc 40, Pd6) <br />_Rcquircd btlcr of Notificat(rn <br />_l ccrlily that lhc fcdcralrcgulati()ns rcgddinB astrcstos rcrmlal{c not applicablc to this projcct. <br />(f,I ccnili tlar I luvc rcad this applicatiqr dxl stalc that irlilunill ion <br />ordimccs and Slalc kws rclating b buiHing <br />ah)ve menti()ned f()peny frrr inspcction <br />Applicant or Agot <br />I'cmrilcc nunrc <br />hcrcby authorize <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 Rouoh <br />Ceilinqs (T-Bar Rouqh) <br />lMeter Release <br />Rough <br />Service lVleter /\\ <br />FINAL o-("7n \rullt \6) <br />Notes Remarks Etc. <br />Date:- <br />I