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ELECTRICAL.INSPECTOR RECORD <br />I hcr€by affinr uilcr p€nahy of pcrjury that I tuD cxenpt [roD lhc Cbnt.aclo6' Liccnse kw for thc following Gaen (Sdc.7031.5 <br />Busincss ard Proltssion C{xlc): Any Cily or County which rcquircs a lrcrmit to construc(, altcr, irnprovc. demlish or rcpair any <br />slructure, prior 0 ils issuatrce. also requircs lhe applicilil ti)r such pcnrrit k) fih a sigDcd stalctrEnl lhat IE or shc is liccled nur$ant <br />to thc pmvixions of llE Conlrachr's Liccnscd lrw (Chafler 9. Commcncing wilh Scction 7000 ol Division 3 of thc Busincss and <br />Profcssions Code) or that hc or slE is exeDrpl thercfrom and tlE baris tor the alleged exemption. fuiy violatiu of Secti(D 703 L5 by aDy <br />npplicant lbr a pernit subjccts the applicunt to n civil pennltv of nol ,mre than five hundred dollars ($500). <br />_1. as owncr ol llr proFny, or my crnphyccs wilh wagcs as thcir solc compcnsdion, will do the work and thc structwc is ml <br />irlerxlcd orofTeredforslc(Se.TlX4.BusincssanrlPrcfcssionsCod.:ThcContraclor'sLiccnsclawrlcsnolapplytoanowncrof <br />the tmpeny who tNilds or improvcs tlErdrl and who does such work himself or lEr$elf or tkough his or her owD enlployees, <br />providcd lhat such improvcmnts ilc mt inlcndcd or ollcrcd Io, salc. Il: howcvci tlrc building or irDprovcrrcnt ir skl within onc ycd <br />ofconpletinr, the owrer Builler will luve thc burden ofprcvirf thd lE or shc did Nt buill or inprcvc thc prcpdly for th. purpos of <br />uh). <br />-1. <br />o owner of thc profEny, om cxclusilely contrscting with liccnsd contraclos lo conslruct t[E preFct (Scc. ?O14, Businc$ <br />and hofbssionCode:TheContrack,r'sLicenseLawdoesnotapplyklanownerofpropcnywhobuildsorinrprovesthereon. <br />and who conlracts for such p(tj('cts wilh a Contracto(s) liccNd pursumt to lhc Contraclor's Licc[e Llw). <br />Dale:_ <br />woRKEt(s' c()M Pr,NsA'It0N <br />DECLARATION <br />I hdrcby allirnl uilder pcnalty of pcrjury one of thc l(ilk)wing dccltuations: <br />_lhavearxlwill truinlainaCenilirateofConsenlloSelf-lnsureforworkersicomJtosation,as providcdforbyScctionJT00ofthe <br />Latrr Codc. for thc pcrforiluncc ofthc work for which tlrc pcrnit is issued. <br />_l have ud will nrainlain workem con[ensalion insuftncc, as required by Scclion 3700 ofrhe labor Code, for thc lErfornLilrce of <br />llrc work lhis is policY numhcr mc: <br />0CJ^4 (q tQ_ <br />Policy o <br />_l ccnily llDt in thc Frli)rnuncc ol thc wo* for which tlris Frmil is isrucd, I shall not cnuloy uy Frson in any manncr <br />so as to becorft subjccl lo lhc workers' conlpcnsation laws of Califomia, and atrce that if I slnuld becom subjcct to thc <br />workcrs' cotrrpensdtion provi5ions of Section 3700 of the Labor Codc, I shall, fofrhwith con)ply wilh thos provisions.. <br />-lanlexemilundet,Sccti()[-'B,&P,C.liilthisreason. <br />WARNINGi Failurc to sccurc workcrs'compensation covcroge <br />civil Iiues up to onc hundred thousand dollars ($100.000). in <br />Section oI intcrcst md dtorrcy s fccs. <br />I,ICENST]D CON'IRACToR <br />I)I](]I,ARA'I'IoN <br />I hercby affirnr undcr Fnnlty of perjury that I am liccnsd uDdcr povision ofChaprer 9 (conurEncinB with Scdtion 7000) of <br />rry':i,fl ,il,il:':f ',i:"T#,1fi 5'nil: <br />Q €1€ <br />aWP <br />of the <br />Liccnsc <br />Busincss and Prcfcssions Codc. and nly lrcen\e is in lull forcc and ellcct- <br />9 ) <br />W <br />I hcrcby afhrm undcr pcnahy ofpcrjury that thcrc is a construction lcnding agcrcy fo, thc pcilormarcc oflhe work lbr which this pcrmir is <br />issucd (Scc. 1097, Civ. C.). <br />kn,lcr's Nam: <br />[rndcr's Addrcss: <br />APPLICANT DECT,ARATION <br />I M)y aflim undcr Fnahy of pcrjlry orc of thc folk wing deldalilns: <br />Dcnx,litioo Pcrmits-Asbcsk)s Notification Federal ReSulati(,ns (Titlc 40, Pd6) <br />_Requircd [*(cr of Notificatioo <br />_l ccnily lhal thc fcdcral rcgulations rc8{ding asbcslos rcrmval uc not applicablc to this proj€t. <br />(!l ccnify that I luvc rcad rlus application ax.l state lhal lhc ah)vc intirmEtion is corcct. I agre to conDly with all Cily and County <br />ordinances md Stalc [a$s rclating to building atxl hcrcby autlnria rcprcsntativcs oflhis Ciry ild thu <br />dbovc lrentioned propcdy for inspcction <br />Applicant or ASst <br />Pcmrilcc nanrc <br />DATEAPPROVALS ID/SIG.COMMENTS <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <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 (Rouoh) <br />Ceilings (Hard & Soffit Rough <br />Ceilings (T-Bar Rough) <br />lVleter Release <br />Rouqh <br />Service lVeter l <br />FINAL to-l0rA tr"\L\[) <br />Notes, Remarks, Etc. <br />,'Q,^. <br />Rev.08-07-2015