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ELECTRICAL{NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUII-DER I'ELCARATION <br />I hcrchy allirm lndcr pcnalty of pc{ury lhal I m cxcmpt Irom lhc Conlraclors l-iccnsc l,aw li)r lhc li)llowirg rcason (Scc.70-}1.5 <br />Busilcss and Prolission C(x-lc): Any Cily or (ounty whiel rcquilcs a lrrnril l() conslnrel. altcr. improvc. r.lcmrlish or rcpair an1' <br />slruclu'c.pri()rk)ils issuance.alsorcquircsrhcapplieantfhrsuchJErrnillolilcasilncdslrtcnrcnt thalhcorshcisliccnscd pursuant' <br />to thc provisi(rls ol'lhc Contraclor's [-iccnscd l-aw (Choplcr 9. Conrnrcncinc with Scclir)n 70ffi of Division .] of lhc Busirlcss anJ <br />Proli-ssionsCo.lc)orthallrorshcisercmptthcrcliomrndthcbasisli)rlhcallcgcdc\cmltion. AnyviolalionolScctitrnToJl.5hyany <br />applicant fi)r , pcrmit srhjccts thc apflicant kr a civil pcnally of nol morc lhrn fivc huntlrcrl rlollars ($5fi)). <br />_1. as owncr of thc prolrcny. ()r my cnlployccs with wages os thcir s(,le compcnsat ion. will do the work and thc structuc is not <br />intcndcd orollcredlbrsalc(Se.T044,BusincssindProltssionsCrxlc:-fheContractr)r'sLiccnseLlwdocsnotapplytoanowncro[ <br />the pnrfrcny wkr huilds or improvcs thcB)n. ml who d(rcs such work himscll or hcrsclfor through his or hcr own cmployccs, <br />pr()vidcd that such imp()vemnts m not intcndcd or olltrcd t'or sxlc. If: howcvcr. thc huilding or imprrvemnl is sold within onc ycil <br />ofcompletinl, tlE Owncr Buildcr will hnvc thc hurdcn ol provurS lhal hc or shc drd Ril huiu or irnprovc thc pn)Faty li)r lhc puqDrc of <br />salc). <br />_1, {s owncr ol'thc propcny. anl crchsivcly conlracting wilh liccnscd conlr{ct)rs k) conslnrct thc p(tccl (Scc. 7044, Busincss <br />and PnrlbssinCodc:'fhcContrack)r's1-icenscl-awdocsnolApplyk)dnowncrofpropcrlywhohuildsorimprovcslhcrcon. <br />anrl who conlracts li)r such prrjccts wilh a C:ontraelor(s) liccnseil fursurnl k) thc Cirilrack)r's Liccnsc l-aw). <br />Iamexcmplundcrselxnl-.B,&P,C.fbrlhisrcason' <br />WORKERS' COTTIPENSATION <br />DECLARATION <br />I herchy allirm undcr lrcnally of pcrjury onc of lhc lilllowing .jcclaralions: <br />_l have anl will maintain a Ccrtificatc of Conscnl to Sclflnsurc tilr w()rkcrs comlrcnsation. as ptuvi.-lc.l tor hy Sccti(,n ]700 of lhc <br />tibor Codc, lbr thc pcrlomancc of lhc work for which thc pcmlit is issucd. <br />_lhavcandwillmaintainworkcrs comlrcnsalioninsurancc,as rcquircdhySeclion-lT0OoflhcllborCitdc,forlhepcrli)manccof <br />lhe work li)r which this pemit is issucd. My workcrs compcnsalion insurancc caricr :md F)licy numhcr ec: <br />Policv Numbcr: Expires, <br />- <br />_l cr'nily thnl in thc pcrlbrmancc oithc work li)r whie h this pcrnril is issucd. I shrll nol crnphy any;rrson in any manncr <br />so as tr bcconrc suhjcct k) the workcrs'compcnsalion laws ol Califbrnir. ild agrce thnl il I slx)uld hccorc suhiact k) the <br />wo.kcrs'comfcnsalionprovisi(nrsolScclion-1700oflhcLah)rCodc.lshall.li)rthwithcomplywilhthoscprovisions.. <br />IVARNIN(;: Failurc k) sccutc workcrs'eomlrcnsalion covcra8c is unlawlul, and shall suhjcct rn cmph)ycr lo criminal Fnallics anil <br />civil tincs up t) onc hundrcd rhousxnd Jolhrs (Slm.(D0). in adilil()n k) lhc cosl of conrlrcnsalion. damagcs as provided ,i)r thc <br />Scction .1076 of thc l-at$r Codc, intcrcsl nnd dlk)rncy s l-ccs. <br />oau. lo- Z? .Zet4 <br />DECLARATION <br />I hcrcby allirm undcr penalty of pcrjury that I nm licen$d undcr pruvision of Chaptcr 9 (conilnencing wilh Scction 7000) of Division l <br />of thc Busincss {&l P(rltssions Code, anl my liccnsc is m lull tbrcc rurl ellccl. <br />Liccnsc <br />Dale: <br />Numbcr: <br />/o-?3 -Z a( n --.- <br />W <br />I hcrchy al I irm undcr Frcnalty of pcrjury that thcrc is a construction lcndinS dgcncy tor thc pcrlbmancc of thc work li)r which t his permil is <br />issucd (Scc. -1097, Civ. C.). <br />kn,lcr's Nime: <br />Lndcr's Addrcss: <br />APPLICANT DECLARATION <br />I lrcrcby allinil undcr pcnalty of pcrjury onc of thc ti)llowing dcclilatio0s: <br />Dcnxllili()n Pcrmil\-Ashc\los Nolilicati{n Fcdcral RcSulllions (Titlc 40, PM6) <br />_Rcquircd Lllcr ()I N(nilicxtkln <br />_l ccnili thal lhc ltdcrrlrcgulalions rcgd{ing ashcsk)s rcmovalarc nol applicahlc b this lrojccl. <br />_l ccilify that I have rcad this rpplicati(fi dil statc thal lhc rtx,vc iDlhrmrtiiilr is corcct. I a8rcc k) comply with all City and County <br />ordinanccs tnd Statc Ilws rrlating to building constructi(tr1. illd hcrchy aulhorrc rclrc\cnlrlivc$ of this City and County lo cnter ul)n lhc <br />xh)vc nNnt(rlcd ropcdy li)r insl-.-clion purF)scs. <br />Applicsnt or Agent <br />Pr'rnril(c nntrrr I c <br />oate, I o-a7 -Zol 4 <br />Site-Work <br />Underground <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 / Grounding / UFER <br />Transformers <br />Torqueino <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 />Ceilinqs (T-Bar Rouqh) <br />N/leter Release <br />Rouqh <br />Service Meter A <br />FINAL 3-1t-tu v.wlt) <br />Notes Remarks Etc. <br />I <br />,Ai q <br />rnnrimnr:V A - (-'