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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG. COMMENTS OWNER BUILDER U EL CARATION
<br />I hereby affirm under pcnrilty of perj u1y that I run exempt from the ContrnClors· License Law for th e follo.win£ reason (:iec.7031.5
<br />Site -Work BusinL'SS and Profession Coch::): Any City or C'oun ly which requ ires a pennit to constrnct. a lter. imp rove. demoliSh or rep; -.,y
<br />structure. prior to its issuaucc. also requires 1hc appli cant for such penni1 to fi le a si gned statement lhat he or she is lic,·nsed p•
<br />Underqround to the provisions o f the Contrnclor·s Licensed Law (Chnplcr 9. Cornm e11ci11g wi1h Section 7000 of Division .1 of tl1e llusin ...
<br />Po le Bases
<br />Profess ions Code) or that he or she is exem pt 1herefrom and the basis for the alleged exemption. Any violat io n of Section 703 1.5 by an)
<br />applic;mt fo r a pennit subj ects the appl icant to a civi l penalty of not more th;m five hundred doll ars ($500).
<br />Light Standards _I. as owner or 1hc propc:11)', or my employees wit h wages as their sole compensat ion. will do tl1e work and the s1ruetw·e is not
<br />..
<br />' Spas, Pool, Fountains intenck'tl or offered for snle (Sec. 7044. Bus iness and Proft.-ssious ('ode: The C'ontrnctor's License Law docs not apply to an owner of
<br />the prope11y who builds or improves thereon. and who docs such work hi 1nself or herselror through his or her own employees.
<br />Signs (monument) provid ed that such im provements are not intended or om.Ted for s.1le. If. however. the bu ilding or improvement is sold within one year
<br />of completion. the Owner Builder will have the burden of proving that he or she did not build or improve the propc,1y for the puqx:ise of
<br />sale).
<br />Life Safety /Low Voltage _I. as owner of the prope11 y, run exclus ivel y contracting with licensed contractors to constnict the project (Sec. 7044. Busin~s
<br />rmd Pmfession Code: T he Co nt ractor's Lic ense Law does nol app ly to an owner o f pro perty who builds or improves thereon,
<br />Fire Alarm / Dampers and who contracts for such projt.>cfs wit h a Contrnctor(s) licensed pursuan t to the Contmctor's License Law).
<br />Commun ications Cab le _I mn c.'(cmpl under Section . B. & P.C. fo r this re1Li.on.
<br />Ul\tC: Owner:
<br />Buildin!J W O RK ERS ' COMP ENSATION
<br />D ECL A RATION
<br />Under S lab / Floor I hereby affir m tmder penalty of peijury one of the following declarations:
<br />Bonding / Ground ing / UFER _I have ru1d will maint ain a C'c1i ificatc of Consent to Self-Insure for workers· compcns.ition. as provided fo r by Sec1io,1 3700 o f the
<br />Labor Code. for the perfo rmance oft he work for wh ich the permit is issued .
<br />T ransformers _I ha\'c and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the )h .. -rfonnance of
<br />TorqueinQ the work for which th is pcnnit is issued. My worh.,·s· compensation insurance can-ier mid policy number arc:
<br />Sub-Panels Can·ier:
<br />Air Conditioners Policy Num ber: E:-:pires:
<br />Roof Top Equipment _1 cc11 ify that in the performance of the wo rk for which I his perm it is issued. I shall no t employ any person in any manne r
<br />Factory W ired Unit so as lo become subject to lh e workt·rs' compensatio n laws of C'ali forn ict. and ngree that if I should become subject to the
<br />workers' compensation provis ions ofScctio11 3700 o f the Lnbor Code. I shall. fm;hwith comply with those pn:l\"isions ..
<br />Wa ll s (Conduit) WA l~NING: Failure 10 secure workcl's' co mpensat ion co\'crngc is unlawful. and shall subject an emp loyer to ciiminal penalties and
<br />Wall s (Rouqh) civi l fines up to one hundred th ousa nd dollars I00.000). in addi tion to the cost of compcnsnt ion. dnmnges as provided for the
<br />Cei li ng s (Hard & Soffit Rouqh
<br />Section 3076 of the Lalx:ir Code. in1 crcs and at
<br />1cy"s fcc~~~~ t\u\f l)ate: \ ~/Zz../ll,, \N
<br />Ceil ings (T -Bar Rough) p lican l:
<br />LICENSED C O NTIU!;;TOR
<br />Meter Re lease UErLARA T I Ojll
<br />I hereby affirm under penalt y of per:!;!J: that I ru n · e nsed under provision of Chapter 9 (commencing with Section 7000) of Division 3
<br />of the Business and Professio ns Code, and my license is in full force and effect.
<br />Rouqh ~1 /'J-I (}-s "\) ·:-,~ l ~ s 6 ()SI 3-,, ; Li cense Class : License Number :
<br />Service Meter
<br />Date: \ l (1--Z-L I t,.,, Crl!.1-{j( L,)"" \-c.. e '€.c iv-. ,.__. , J'~.-✓,l---< \.
<br />FINAL <}-/')-/ I"). '--:, \ r,-,:
<br />C s ,{we I ION L EN DING AGENCY Note s, Remarks , Etc. / .,
<br />! hereby affirm u11de1: penalty o f perjury that 117 is~uctio11 lending agency for th e perfonnance o f t he work fo r which this perm it is
<br />issued (Sec. 3097. Civ. C.). 1
<br />Lender 's Name:
<br />Lender· s Addre ss :
<br />,\PPLlrA NT UE!:;LA llATIQN
<br />I hc.,·cb), affinn under penally of perjury one of t he rollowing declarations:
<br />Demo lition Permi ts-Asbestos Notification f edera l Regula1ions (Title 40. Pa11 6)
<br />_Requ ired Letter of Notificat ion
<br />_I ceitify that the federal regulations regardi11g asbestos r emoval are not applicable to this project.
<br />·-cci1ify I t I have read this application aud state tha t the above in fonnation is co1Tcc1. I .igi-cc 10 comply wi th .i ll City and County
<br />ore m,1 cs, d S!nle Laws rdn1mg lo bu,ldmg conslrnc<,on.z hereby ~rL~cnln.,,c~ ofllus C11; ,md Counly 10 cnlcr upon 1hc
<br />nb01e me 0t)ncd pwpcny for mspcctoo~__,,,-/ -
<br />A ppr a nt o ~:Z.-t Sign.,tu ,e / Da l e
<br />l'er ~•itcc m,n (pl int): ~\ ✓ (.\_ l,.,,_ -Hu& e ~V\
<br />t:i,....., ni? n ··; ')fl'! i:: Y---
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