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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUII-DER DELCARATION <br />I hcrchy aflirm undcr pcnalty of pcrjury that I am cxcmpt frnn thc Coolraclors' Liccnrc kw for thc following ro$n (Ss.?0.11.5 <br />Busincss and Profcssion Codc): Any Cily or County which rcquircs a lErmil k) cotrslrucl. allo. irnprove. {cmlRh or rcpair any <br />struclurc. prior to ils issuancc. oho rcquircs lhc applicant for such lrcrmit to filc a signcd slalcmnl lhat hc or shc is liccnscd Ftripanl <br />to lhc prcvisions of thc Contraclor's Liccned Law (Chaptcr 9. Conrncncing with Scclion ?fix) of Division 3 of thc Buslncss and <br />Profcssiors Code) or lhal hc or shc is cxcmpl lhcrefron and thc b{sis firr thc allcged cxcmplion, Any violution of Setion 70-1 I .5 by any <br />rpplicnnr for r pcrmit subjects thc applicont to a civil pcndlty of nol morc than five hundrcd dollars ($500). <br />_1. as owncr of thc pro1rcrty. or rny ctnployces with wagcs as lhcir solc cornpcnsalion. will do thc work and thc structure is not <br />intendcd or oftered for salc (Scc.7044. Busincss and Protbssions Crdc: The Contractor's Liccnsc Law tklcs not apply to an owncr of <br />the property who builds or itnprovcs thcrcrrn. and who <locs such work hirnsclf or hcrself or through his or her own cmployecs. <br />;trovidcd that such irnprovenrcnts arc not intcndcd or offcrcd firr sah. lf. hou'cvcr. thc buildirtg or intprovctltctll is sold within onc ),cilr <br />of corrrplction. thc Owncr Buildcr u'ill have thc burdcn of proving that hc or shc did not build or im;rrovc thc propcrty for thc purp)sc of <br />sulc). <br />_1. as owncr of the proprty. am cxclusivcly contracting with licenscd contraclors lo conslrucl lhc projccl (Sec. 7M4. Busincss <br />and Profcssion Code: Thc Contractor's License Law docs nol apply to an owner of propcrty who builds or improves lhcreon. <br />and who contracts for such projccts with a Contractor(s) liccnscd pursuant to the Conlractor's License l-aw). <br />-lanrcxcnlDtundcrScction-.B.&P.C.lbrtlrisrcason.Dale: Owner:- <br />WORKF' RS' CONT PENSATION <br />DECLARATION <br />I hcrcby affirm undcr pnalty of pcrjury one of thc following dcrlarations: <br />_l havcandwill maintainaCcrtificatcofConsentloSelf'-lnsurcforworkcrs'compcnsalion.as providcdtbrbySeclion.lTfi)ofthc <br />I;rbor Codc. for lhc Jrcrformancc of thc work for which thc pcrntit is issucd. <br />-l <br />lravc and will rttainlain workcrs' cotnpctlsation insuriutcc. ils hy Section -17(X) of tlrc Labor Codc. lbr thc pcrforntancc of <br />carricr and policy nuntbcr are:lhc work firr which this pcrntit is workcrs' <br />Policy <br />_t ccrtily that in thc pcrtirrrruncc of thc work for which this Jrcrrnit is issucd. I shall not cmploy any person in any nlanncr <br />so ls to bcconrc sub.|cct to thc workcrs'compcnsalion laws of Calilirrnia. and agrcc that if I should hcconrc suhject to thc <br />workcrs' conrpensalion provisiolrs o[scctiorr 37fi) of thc Lahrr (ixlc. I shull. ltrrthrvith corrrply r.r'ith thosc provisions.. <br />IVARNING: Failurc l() sccurc workcrs' conrpcnsation c()vcrtgc is urthwl'ul. and shall suh.icct urt cnrpl<lycr to criminal Jrcnaltics altd <br />tion. darnages as proviclct fur tnccivil lirrcs u1l to orrc hurtclrccl tlrousand dollars (SlU).(XX)). in ntl<l lo thc of-."t'j:[Tq*inlcrcsl artd <br />I hcrchy allirrn undcr Jrcnalty of pcrjury that I am liccnscd undcr provision of Chapter 9 (conrmencing with Scction 7Un) of Division 3 <br />of thc Busincss and Pr<lfessions Codc. and my licensc is in f'ull frlrcc and cffect. <br />l-iccrrsc L <br />r,",. zB')}..[? <br />cONS'l'RLl("1'l( )N L!:N I)lN(; AG !.NCl' <br />I hcruby affirm undcr lrcnnlty of pcrjury that thc]e is a construcliil lcnding agcncy for thc tErfortrnncc of lhc work for shich lhis FYmit is <br />issucd (.Scc. 3097. Civ. C.). <br />[.cndcr's Namc: <br />APPI ICAN'I DECLARATION <br />I lrcrcby aflinn under pcnalty of pcrjury one of the fbllowing dcclarations: <br />f)cmolitiorr Permits-Asbcstos Notification Federal Regulations ('l'itlc 40. Part(r) <br />-Required <br />lrtter of Notilicatiotr <br />_l ccrtify that thc fcdcral rcgulations rcgarding asbeslos rcrtxrval arc nol applicable to this projcct. <br />_l ccrtify that t havc rcad this applic:ation and statc that the ahrvc inlirrrnaliorr is correct. I agrcc lo cortrply with all City and (--ounly <br />ordirranccs ancl Statc Laws rclalirtg to ard hcrchy aulhorizc rcprcserrlativcs oI this Clity and County lo cntcr ugrn lhc <br />lbovc rncrttioncd propcfly frlr <br />Applicant or Agent <br />lft.rrnilct llanle ( ;rrint ): <br />Site-Work <br />Underqround <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under SIab / Floor <br />Bondinq I Groundinq / UFER <br />Transformers <br />Torqueinct <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 Rough) <br />Nleter Release <br />Rough <br />Service NIeter <br />FINAL t 7lfi lt4 b*firlc L+ b? <br />Notes, Remarks, Etc t t, <br />t() t-t7 Dni H <br />ExPires: <br />a <br />Class:4,," <br />t <br />)^t