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ELECTRICAL-INSPECTOR RECOHD <br />APPROVALS DATE !D/SIG.COMMENTS OWNER BUIT-DER DELCARATION <br />I hercby alfiror undcr pcnalty ol pcrjury lhfll I trn cxeillpt liofi thc Contrilck)rs' Liccnsc [,aw lor lhc lbllowirrg rcason (Scc.7031.5 <br />lrusincs\ and l'rofcssion Codc): Any City or Counry which requircs a FErtrril to conslrucl. altcr. inrprovc. tlcrrtrlisl or repair any <br />sttuclurc.pri()rloils issurnce.alsorequircslheapplicaniforsuchFrnlillolilcasigocdslalcnEilt lhathcorshcisliccilscd pursu{nl <br />lo lhe prcvisk)trs of thc Conlrachr's Liccnscd l-aw (Chtrplcr 9. Conrnrcncing with Scclion 7(X[ of Division 3 of the l]usincss:rnd <br />ProltssionsCodc)orthatlrcorshciscxcnrpllhcrcliomandthcbarisl'()rthcallcgcdcxcmplion. AnyviolntionofScctionT{).ll.5hyany' <br />applic{ntforapcrmitsuhjcclsthc applicanltoacivilpenaltyofnoltrhrcthilnllvchutrdreddollilrs($5(x)). <br />_1. as owncr of I hc pro|[ny. or my enrployccs wil h wagcs as lhcir solc conrpcnsal ion. will do lhc work ffil tlE slmture is nol <br />intcndcd orollcrcdforsalc(S8.7(I44.BusincssandProfcssi<rnsCodc:ThcConlmctor'sl,iccnsclawdocsnotapplytoanowncrof <br />thc pmpcfly who builds or improvcs lhcrsnr. ud who d@s such work hiNsel, or hcrscll or through his or hcr own cmployecs. <br />providcd that such impmvcmnls arc ret inlcftle{ or offcrcd lirr qh. ll. howcl'cr. thc huilding or irprovcnrcnl is $kl within onc }qr <br />ofconrplction. thc Owncr Buildcr will havc thc hurdcn of proving lhat hc or shc did not huild or improlc lhe pm[Eily for thc purJhs of <br />sah). <br />_1. rs owncr of lhc propcrty. ah cxclusivcly contraclin8 wilh liccnscd conlrncbrc k) conshrcl thc prliccl (Scc. 7044. Busincss <br />and Pnrli:sshnCodc:'l'hcC-onlraclor'sLiccnscLawdoesnolapplyloilnowncrofpropcrtywhobuildsorimprovcsthcrcotr. <br />and who conlracts li)r such projcrts with a Corilractor(sl liccnscd lursuaDl h lhc Conlraclor's Liccn* hw). <br />I iltrr cxcnrnt undcr Scrli()n . B. & P.C. li)r lhis rcrson. <br />I )illr Owner: <br />WORKERS' COT\IPENSAl'ION <br />lll.:CLARATION <br />I herchy alllrm undcr pcnaltyof pcrjury onc of the lirllowirtg dcclarations: <br />_l havc and will mainlain a Ccnilicate of Consnl kr SelLltrsurc for uorkers ()mpcnsxlion. as proridcd lbr hy Section .17(X) ol thc <br />latxrr Codc. lirr thc pcdorilrncc ofthc work for which thc Jrcrrnit is issucd. <br />_l havc and will rnainlain workcrs' conlpcn\ation insurdDce, as requircd by Scclion -17(D oflhc tnbor Code. for thc pcrformancc of <br />thc work lor which this pcrmit is issucd. My workcrs' conrpcnsntion insurancc cdricr rnd policy numbcr uc: <br />.^.,",, ' Fr.t.err no\.rrr ar I T.r\ , rna^.€ <br />0.,,.r*,,,,,n", I ?6090 [1t16[Bi - F.*ti,",,' z-L-lol <br />_l ccnili thnt in thc lcrli)rmancc of lhc work li)r which lhis pcrntit is issuc<|. I shall not cnrploy aly pcr\on in any nranncr <br />s()[slohcconrsubjccllolhcworkcrs'cotrrpcnsrlionlilwsofCalilornir.rndrgrcelhrtiflshouklbecoillcsuhjcclkrlhe <br />s'orkcr\'coDrpcnsalionprovision\ol-Scction-17(X)ollhcl.ah)rCo(lc.l\hall.lirlhsithcomply$'iththo$pro!isions.. <br />WARNING: [aihrc to st'curc s()rkcrs'conpcilsnlion covcrxgc i\ unlawftl. and shall subjcct xD cnrpl()vcr lo oiminal ptnrltics and <br />civil fiDcs up to onc hutrdrcd thorsand rlollars (Sl(X).(XX)). in ad(lilion k) lhc cosl ol'compcn\alioD. dlmagcs as proli(lcd f'or lhc <br />Scciion .1{)76 oI lhc l-alx)r Codc. inlcrcsl iil(l ntkillcy s fccs. <br />o",", rQfl1.,L Applicont: 4 <br />DECLAR,{TION <br />I hcrcby alllrnr undcr pcnally of pcrjury that I [m liccnstl u[dcr p()vi\ion of Chaptcr 9 (cornnrcncing uith Seclion 70(x)) of Divisk)n 3 <br />of thc Busincss and Proltsshns (irde. and tny liccnsc is in llll forcc ilrd cllact. <br />I -iccttsc <br />l)ate: <br />,,a"rr"^r,,r,n",, t Ql3 Q ) f <br />a4L7o cont.o"t,,.,;( d-5-aaq{ 3.o.r.l <br />W <br />I hcrchy affirm under Jrcnillty ol pcrjury thal lhcre is I construction lcnding ugcncy for lhc Frerforn[ncc oflhe work for which lhis frcnnil is <br />issucd (Scc. 3097. Civ. C.). <br />APPLICANT DECLARATION <br />I hcrcby allrm undcr penally of pcrjury one of thc following dcclarut irrts: <br />Demolilion Permits-Ashcslos Nolification l:cdcral Rcgultrtions (Tillc 40. Pan6) <br />_Requircd kller of Nolification <br />_l ccrlify thal lhc fbdcralrcgulelions rcgrrding ashcstos rcrnovalarc not ilnplicrblc k) this pr(&ct. <br />Sl ."nify rlur I havc rcad this application {nd slalc lhal lhc atnvc inlbrmdion is corcct. I agre lo comply with trll City and County <br />ortfinanccs and Slatc [aws rcluting to building conslruclion. and hcrcby authorizc rcprcscnlatives of lhis City and County to cntcr ulx)n lhe <br />iltx)\'e trrcntioncd pft)pcfly ti)r inspcction purf)scs. <br />Al)plicnill or A,:rnl <br />l'errrrileenrnrelprintl: ( B fi.n^ <br />^ <br />lin <br />l)il1(:'31'?.!s <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 />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 (Rouoh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinqs (T-Bar Rouqh) <br />N/leter Release <br />Rouqh <br />Service Meter <br />F!NAL <br />Notes, Remarks, Etc <br />-t <br />hndcr's Narm: <br />- <br />kndcr's Addrcr.: