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ELECTRICAL.INSPECTOR RECORD <br />[- <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI-CARA'TION <br />I hoeby aflirrn lndq pshhy of pnjury that I or cxempl from lhc Conlraclo6 Licc$e Law for thc follorving reaFn (5(.70-11.5 <br />Business and Prof6sion Code): Any City or County rvhich require a pmnit to construct. alta. improvp. dcmolish or rqkir Uy <br />strlcl$e. prior lo ils isuance. also requirB lhe applicilt for such pmil to file a signed statmol that he or she is licosed pursuanl <br />to thc provisions ofthe Contmclor's Liccnsed Law (Chapter 9. Cornmencing with Section 7000 of Division 3 ofthe Business and <br />ProfesionsCode)orthatheorsheisexernplthsefromddlhebasisforlheallegcdexqnplion. AnyviolationofsstionT0-1l.5byan! <br />applicsntforapmnitsubjcctsthe applicantloacivilp€naltyofnottnorethanfivehundreddollils($500). <br />I. m os ner of the profsly, or my employeG with rvage m their wle compensation. rvill do the work md the struclue is not <br />inlodcd oroftsedforslc(Se.TO44.BusioesandhofesioNCode:TheConlraclor'sLiceNelrwdo6nolapplylomo\rnerof <br />thepmFny rvhobuildsorimprovsthq@n.ild$hodo6such*orkhimselforhereelforthreughhisorhoowncrnploycs. <br />providcd that such improvments de not intoded or offqed for sle. If. howw6. the building or improvemenl is sold rvithin one reu <br />ofcomplaion, the Owner Buildo s'ill have the burda ofproving thd he or she did not build or irnpove the prepoty for the pur1nsof <br />sle). <br />l. as orvner ofthe propcrty, an exclusively contracting wilh licosed contractors to construct (he project (Sec. 7044. Busine$ <br />and Profsion Code: The Conlraclor's l,icense Larv doe not apply to an orvno ofproperty ivho builds or improves lho@n. <br />and who contrads for such prejsts with a Conlmcto(s) liceNed pursuant to lhe Conlraclor's Licose l-aw). <br />I m exemDt undcr Setion . B. & P.C. for this reaon. <br />l)ate:Onncl <br />-rYaB[!;sSrQUeNSArrON <br />DECLARATION <br />of lhe folkrrving dclarations:I hdeby amrm und6 pmalty ofpojury one <br />_l have md rvill rnaintain a Certilicate of Consml lo SelHnsure for sork6' composation, c provided for by Setion 3 700 o f the <br />Labor Code. for the pqfonnmc€ ofthe work for which the porit is issucd. <br />_lhaveandrvillnrainlainworkers cornpensationinsurance.6 rcquiredbySection-1700ofthet,aborCode.forthepqfonranceof <br />lhe \rork for which this ponil is issual. My works' compenslion insurance caria md policy number aer <br />Cmio:- <br />Policy Number:-Expires: <br />I ccnify that in the performance ofthe rvork ior which this permit is issued. I shall nol ernploy any person in any man0er <br />m c rr become subjel to lhe \r'ork6' compcnsation laws of Califomia. and agre that if I should become subjel lo lhe <br />workss' cornposalion provisions ofSection 3700 oflhe t,abor Code. I shall. forthwith comply with lhos provisions.. <br />WARNIN(;: I,-ailurc to sccurc workeN' coilrpcnsalion covcrage is unlarvful, and shall subiecl an cnrploycr to crin]inal peilaltis and <br />civil fins up to one hundred thouend dollds ($100.000). in addilion to cosl of coillpcnsation. danrages as proYidecl for thc <br />atomey s fe. <br />DECI.ARATTON <br />I heirby affirrn unde penrlly of perjury that I an licmsed under provision ofChaptd 9 (comnrmcing with Section 7000) of Division 3 <br />of the Busins and Profasions Code. md my licase is in full force ad effat. <br />Liccnse Class:_Nuntrr: <br />,",", f\l? I \? <br />CONSTRUC'IION LENDING ACENCY <br />I hocby affirm undr poally of pcrjury that th6e is a conslruction lcndirg agmcy for the pofomrmce of the u'ork for which this prnit is <br />issued (Se. 3097. Civ. C.). <br />L€nd6 s Narnc: <br />l-endcr's Acldrss: <br />APPLICANT DECLARATION <br />I hetby affmn unde penahy ofpnjury one of the follorving d(ltrations: <br />Demolition Pqmits-Asbstos Notification Fedtral Regulations (Tille 40. Pan6) <br />Rcquired Letter of Notificalion <br />-l <br />cstify that the federal regulations regilding abestos removal are not applicablc to lhis prcjtrt. <br />,l cfiiry thal I have read this application dd state lhat the atnve infonnation is cof,st. I agre to comply lvith all Cily and Coutrly <br />ordinanccs and Slatc [-!\\'s rclating lo conslnrclioff. md h6eby aulhorize rcprscntaliYcs ofthis Cily and County lo enlo' ugrn lhe <br />above molioned prop€Tty for <br />Applicnnl or Agent Signature: <br />Pemile nemc (print)l <br />,",",[ Uz/11 <br />Site-Work <br />Underqround It-l;'t1 JJ a!1,r.Y U /,,L,ut- <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 />Bonding / Grounding / 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 />Cellings (Hard & Soffit Rough <br />Ceilinqs (T-Bar Rouqh) <br />lt4eter Release <br />Rouqh <br />Service Meter <br />FINAL l.-77-u \\)llr.)( <br />Notes, Remarks, Etc.'J <br />GI <br />J <br />/dL,J <br />\