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ELECTRICAL-INSPECTOR RECORD <br />n0 rl7 1n -i r <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION <br />I hcreby alfirnr undcr pcnrlty of Frjury lhar I mr excmpt fmm lhc Contraclo6' Liccnsc l-nw lbr thrfolhwing rosryr (Scc.70.11.5 <br />Busincss and Profcssion Codc): Atry Cily or County which rcquircs a 1rcnnit to construct. altcr. improvc. domlirh or rcpair any <br />slruclurc, prior to its issuarcc. also sluircs thc applhant for such Jrcrmit to file u signcd stalemtrl that hc or shc is liccnsd pu-,suttl <br />lo the pmvisions of tlrc Conlrsclor's Licenscd llw (Chaptcr 9. Commcncing with Setion 7()0O of Division 3 of lhc Busircss and <br />Prcfcssk)nsCodc)orthathcorshciscxcmptthcrcfromandlhcbasisforlhcallcgcdcrcmplion. AnyviolalionofSccthnT0-il.5byany <br />aIrplicanl for a pcrmil subjccls thc applicant to u civil pcnalty of not morc thiln fivc hundrcd dollars ($5(x)). <br />_1. as owncr of the proprty. or nly cntployccs with wagcs as thcir solc conrpensalion. willdo thc work and the slructure is not <br />irrlcntlcd or offcred f<rr salc (Scc.70.14. Busincss and hol'cssiotrs Coclc: 'l'hc Contractor's Liccnsc Law d<lcs not aPply to an owncr of <br />thc propcrly who builds or itnprovcs thcrmn. and who tloes such work hirnsclf or hcrsclf or through his or hcr own enlployccs. <br />providc(l that such inrprovcnrcnts are not intcndcd orotTercd ttrr salc. lt. howcvcr. thc building or improverrnt is sold withinonc year <br />of cotnpletion. thc Owncr Buildcr will havc thc burdcn o[pnrving lhat hc or shc did not huikl or itttprove the propcrry for thc purprsc of <br />salc). <br />_1. as owncr of the propcrty. ant exclusivcly contracting with licenscd contractors to conslruct thc pntjcct (Sec. 7M4. Busincss <br />and Pnrfession Codc: Thc Contraclor's Liccnsc Law does not apply to an owncr of propcrty who builds or improves thcreon. <br />and who contracts firr such projccts with a Conlractor(s) liccnscd pursuant to thc Contractor's License kw). <br />-l <br />anr cxcmpt under Scction-. B. & P.C. for this rcason. <br />Dale: _owner:- * -WORKERS' COI\I PENSATION <br />DECLARATION <br />I hercby affirm undcr Jrcnalty of perjury one of the following dcclarations: <br />_l have and will maintain a Certificatc of Conscrrl lo Sell'-lnsure for workers' cornpcnsalion. as providcd for by Scction 3700 of the <br />l-ahor Code. for lhe pcrformance of the work for which thc pcrnrit is issucd. <br />_t havc and will maintain workers' compensation insurancc. as rcquircd by .Section 3700 of thc Lrbor Codc. for thc pcrformance of <br />lhe work for which this permit is issucd. My workers' compensation insurancc carricr and plicy nuntber are: <br />Policy Number: ExPircs: <br />_l certify that in the performancc of thc work for which this Jrcrrnit is issued. I shall nol cnrploy any person in any manncr <br />so as to bcconr subject to the workers' compcnsation laws of California. and agrcc thal if I should become subjcct to lhe <br />workcrs' compensation provisions of Section 3700 of thc Latnr Codc. I shall. forthwith cornply with those provisions.. <br />WARNIN(i: Failurc to sccure workcrs' conlpensation covcragc is unlaw{'ul. and shall suhjcct an crnployer to crinrinal Jrcnaltics and <br />civil lincs up to olc hundrccl thousand dollars (Slm.(Xn). in addition to thc cost of conrpcnsalion. damages as provided for lhe <br />Sectiort 3076 of thc l.atxlr Codc. intcrcsl and attorrcy's l'ces. <br />Appliurnt: <br />DECLARATION <br />I herchy afifirm undcr penalty of perjury that I anr ticenscd under provision of Chapter 9 (comrrcncing with Section 7fiD) of Division 3 <br />of thc Business and Prol'cssiorrs Codc. and my license is in full forcc and cffecl. <br />Liccnsc Nunrhcr: <br />l )nle : ( 'ottt r:tclttr <br />C( )N.S'l'Rtl("1'lON LI-N I)ING r\( J liN('t' <br />I hcrchy affirrn undcr JrcnaltyofFrjury thnl thcrc is il cotrstructioil lendirg ogcocy for lhc pcrformancc ofthc work for which lhis frcrDil is <br />issucd (Scc. 3097. Civ. C.). <br />Lrnder's Namc: <br />APPLICANT DECLARATION <br />I hcrcby affinn undcr penalty of pcrjury oltc of thc following declarations: <br />Dcrnolition Pcrrnits-Asbestos Notification Fcdcral Rcgulations (Titlc 40, Part6) <br />-Rcquired <br />Letlcr of Notification <br />_l ccrlity that the fcdcral rcgulalions rcgartling arsbcstos rcnrot'al arc nol applicablc' to this projcct. <br />_l ccnify thnl I hlve read this applicnlkrn and stiltc lhat thc atmvc i[li)rtrulion is coftcct. I agre to conu)ly wilh all City and County <br />ordiranccs and Stiltc liws rclnting lo huilding conslruclion. arxl hcrcby aulhoriz. rcprescot{tivcs of this Cily ond Counly lo cnlcl ulnn thc <br />above rrrcntioncd properly for <br />r\pplicirnt or Agenl <br />Pernritee nfl nle (print ): <br />purp()scs. <br />Date:_ <br />Site-Work <br />Underqround <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildins <br />Under Slab / Floor A <br />Bondinq / Groundinq / UFER I <br />U \J$ftnl) <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 />Ceilinqs (Hard & Soffit Rouqh <br />Ceilings (T-Bar Roush) <br />N/eter Release <br />Rouqh A t A <br />Service N/eter l0-I *dr*n <br />FINAL o )h0 ft hu +W <br />Notes, Remarks, Etc lr l\l <br />L