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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUIt,DER DELCARATION <br />I hcrcby alfirm undcr pcnally ol FErjury thdl I nm cxcmfl lilnn lhc Contraclors' I-iccnsc Law li)r thc li)lbwing rcason (Scc.7031.5 <br />Busincss and Prolission Crxlc): Any City or County which rcquircs r lErnlil lo conslrucl. allcr. improve. dcnxrlish or rcpair any <br />\tnlclnre.pri()rkrils issurncc.alsorequircsthcipfhcanttbrsu(hlErmitlotilcrsigncdstalcnEnt lhatlrorslEi{liccnsd pursrant <br />Io thc provisions ol thc Contraeklr's Liccn*d hw (Chnp(cr 9. ConrnrcncinS with Scction 7(X) ol Division -l of thc B[sincss and <br />I)rolessionsCodc)orthathcorshciscrcmptthcrcliomandthcbrsisli)rthcallcScdcxcmpti(rn. AilyviolationofScctrrrT03l.5byany <br />upllicantti)rrpcrnlitsubjcclsthc applicdnlk)aeivilpcnxllyol'n(ntrr)rcthrnfivchundrcddollars($5tX)). <br />_1. as owncr ol thc lroFny. or my cnuloycr's wilh waScs as lhcir solc conpcnsxli{)n. will do thc wo* anrl tlt sttutw Ls il[ <br />intctllerl orollcrcrlli)rsale(Sce?()44.BusincssandProt'essions(ixlc:lhcCollrrcl(,r'sl-iccnselrwdocsnotapplyk)anowncrof <br />lhc prulrcrty who huilds or improvcs lhcrq)n, {il who d(rcs such work hinlsclfor hcrscll or lh()ugh his or hcr own empl(}yccs. <br />providcd th{l such irrprovcrrcnls rc not intendcd orotlircd firr salc. ll. howcvcr. lhc huilding or inrprovcnrcnt is sold within one yeu <br />salc). <br />_1. !s owncr ol lh(' profrc(y, am cxclusivcly contricltrrg wIh liccnscd conlrack)rs k) con\lruct thc p(*cl (Scc. 7044, Brsulcss <br />and RotissrxrCixlc:ThcContraclor'sLiccn{cl,rwd(}esnotapplytoanownerol'propcrlywhohuildsorimprovcslhcrcon, <br />and who contracls lbr such p()jccts with a Conlrack)r(s) liccnscd pursuant k) lhc Cl{)ntrack)r's l-iccnsc l-aw). <br />-lamexcmplundcrsection-.B.&P.c.li)rthisrcason. <br />\\ ( )ttKI._RS' ( I )t I I't.tNS,\1 t( )N <br />I)li( t.,\R,tt toN <br />I lrcrcby all irrn undcr pcnalty ol pcrjury one of thc li)llowing dcchrdlrrns: <br />_l hrve drj will maintain a Ccnilicale of Conscnl k) Self:lnsurc k)r workers compcnsation. as povidcd for by Sccti()n -l7OO of thc <br />Ijh()r Gxlc. lbr thc Frfomancc (,[ thc work for which thc permit is issucd. <br />thc work lilr which lhis pcrnrit is i\sucd. My workcrs conlpcnsation insurancc carricr nnd F)licy rrunrhcr u'c: <br />5I'()licy <br />>' f ^l <br />_l ccnify lhat in lhe pcrlhrn]ancc of thc work l'or which this pcrnril is issucil. I shall not cmplrry any grcrson in any manncr <br />q) as to bccorc $ubjecl lo lhc workcrs'compcnsation laws ofCalili)rnia. and agrcc thBl if I should bccom subjcct lo lhc <br />workcrs' coml^-nsalion pR)visiurs ol'Scction -1700 ot lhc tihor Cixlc. I slull. ti)nhwith comply with lho$ pNvisions.. <br />IVARNINO: l:iilurc k) sccurc w()rkcrs'rotrlpn\rli()tr covcrrlc i\shrll subjccl rn cnrploycr k) criminal ,*"L'nnd <br />llrcivil fincs up lo oDc hun.lrcd thousand dollus (S rr nrl,lilir)n e()sl ('l' conrpcnstli()n. rlanrages as <br />Sccti(rn -1076 ol lhc Litx)r C{xle. iilcrcst and <br />I hcrchy atlirm undcr penalty ol p(rjury that I anr liccnrcd undcr provisrrn ofChaplcr 9 (commcncing wilh Scction 7U)0) of Division -1 <br />ol lhe Busircss and Prol-csst)ns Codc- afrl nrv liccnsc is in Iill t'(,rcc ilxl etLet <br />[.iccnse Nrrmn+r: <br />D"t",rdll 1 i lA <br />,r- ( I ' I <br />I hcreby atfirm undcr lrcnalty of FErjury that thcrc is a construction lcnding <br />issucd (Sec. 1097, Civ. C.). <br />knJer's Name: <br />ti)r thc pcrtbrtruncc of thc work IiJr which this Frcrmil is <br />hndcr's Addrc\s: <br />APPLICANT DECLARATION <br />I lErcby allinn undcr pcnalty ol pcrjury onc of thc Ii)llowing dcclnrationsl <br />Dcnx,lilion Pcrmits-Ashcsbs Notilic{tion Fcdcral RcEtht()ns (Titlc 40, P!n6) <br />_Rcquirc'.I hltcr of Nolilicalinr <br />with all City and County <br />and County lo cntcr UFD lhc <br />atx,vc mcnti()ncd prcpcily ti)r <br />Applicanl or Agcnl <br />Pemritee nanre {prinl <br />*, - 1pl lt1 <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 I <br />Bondinq / Groundinq / UFER t7/7D L+w <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 Rouoh <br />Ceilinqs (T-Bar Rouqh)I <br />Meter Release I o -7/)DfV \u >tr, 2 <br />I \ <br />Rouqh I <br />Service Meter V,I ,"L 7t)12rr Y)c >w 67 <br />F!NAL (t 7 '1 t)bilr,l n,*jYl <br />Notes, Remarks, Etc.rl \ l' <br />_> <br />,,t".' A)Z- l lqr, ,l I <br />(Dffnr.. r r <br />\Y