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ELECTRICAL.INSPECTOR RECORD <br />no n7 ,n{ E <br />APPROVALS DATE ID/SIG.COMMENTS 0WNF]R BTI I I,I)F]R I)F]I,(:ARA'[I0N <br />I hcrcby afftrm undcr JEnalry of perjury that I m cxcmpt from thc Contretos' Liccn* [:w for thc following rcasn (Scc.70.tl.5 <br />Busincss anl profcssion Cqle): Any City or County which rcquircs a [Emit to construcl, all6. impruvc. demlish or rcpafu ey <br />structurc. prior to its issuecc. afs rcquires thc applicant for such [rmit to lib a sigred stalcrcnl that hc or shc ir licn$d Pusot <br />kl thc pruvisions of thc Contretor's Lien*d Law (Chaplcr 9. Commcncing wilh Setion 70oO of Division 3 of thc Business 'ndpnrfcssttns Culc) or lhat he or shc is cxempt thcrcfrom md thc basis lor lhc allcgcd exemption. Any violation of Sstion 70J 1.5 by any <br />applicatrt Iirr a pcmit subjects rhc applicanr rr a civil lxmlry of n(rt more lhan fivc hundrcd dollss ($500). <br />_1. as owrcr of thc pmFny. or my employcs with wagcs rs thcir solc coE{Ensation. will do lhc work arxi lhr sth*tE is not <br />intwJol or offcrcrt tu mle 1Se.7O44, nusincss md Pnrfcssions Cillc: Thc Coilr.ctor's Liccns [.w d(rs not apply to m owns of <br />thcpmpcrty wtrttfliLlsorintpmreslhc@[afirwlxrdmssrehw*himsclforhctrclforthrcughhisorherowncmplo)rccs' <br />p^rrilc.t rhur such imlnrremnts re mt intcrxjql oroflbEt for sb. lf, howcu. thc huilling or imlnrwmnt is sU vithin orc )c{ <br />;f $mplction, thc Owncr Buillcr will haw thc bunten of pruving that hc or shc did mt huill or imprcrc the pmtsly fo. the purF)E of <br />sab). <br />_1, $ owncr of thc pofErty, am cxclusivcly contractiDg sith liccnsd contractoN to construct th€ prcj$t (Scc. 7(X4, Busincss <br />anl pofcssbnCodc:TheContrector'sLicenseLawdocsnotapplytoanowncrofprclEnywhobuildsorimprcvesthcrcon, <br />and who q)ntmcts for such Jmjects wilh a contreto(s) liensd pursuanl l() thc contractor's Licen* kw). <br />-l <br />anr cxcmpt undcr B. & P.C. lirr this rcason. <br />Dete: Owner: <br />WORKERS' COI I PENSATION <br />DECLARATION <br />I hereby aflhnr undcr penalty of 5rcrjury one of the folkrwing dcclarations: <br />_l havc arxl will maintain a Ccrtifrcare of Consent to Sclf-lnsure for workcrs' compensation. as pruviderJ for by Section 3700 of the <br />latxtr Codc, for the performance of thc work for which thc grcrmit ls issued. <br />-l <br />havc and will maintain workers'insurancc. as required hy Scction 37fi) of thc Labor Cotlc, lirr thc pertilrmancc of <br />thc work lirr which this pcrmit is issued.c()nrlrcnsalion insurancc carricr and ptllicy numbcr arc: <br />Z /3 <br />l)olicy <br />_l ccrrily that in the Jrcrlbrmance of the work litr which this prnrit is issuctl, I shall not employ any pcrson in any manncr <br />s6 as t11 bec6nrc subjcct to thc workers' comlrcnsation laws ol'Calililrnia, and agrec thal if I should bcconrc subjcct lo thc <br />wgrkcrs' cempcnsation provisions of Scction J700 of thc l-ahrr Ctxlc, I shall, tilrthwith comply with thosc pn)visiolls.. <br />!VARNIN(i: Failurc to sccurc workers' compcnsation covcr:Ulc is urtlawt'ul. and shall suhjcct ttt and <br />thccivil lincs up to onc huntlred thousand dollars (S100,fin). in addition to cost of damages as <br />Scction 1076 of Cule, interest and attonrcy's l'ces. <br />, <br />I hcrcby allirm ulrlcr penalty of pcrjury that I am liccnscd undcr provision o[ Chaptcr 9 (comnrcncing with Scclion 70m) of Division <br />ol' lhc Busincss and Pnll'essions Codc, and my liccnsc is in lull ltlrcc urd cl'l'ect. <br />Liccnsc c/0 C Nunrtrer: <br />I hcr"-by allirm untlcr Srcnaltyof perjury that therc is a conslruction lcnding agency for lhe pertirrmancc tlf thc wtlrk lirr which this grcrmit ls <br />issued (Sec. 1097, Civ. C.). <br />[-ender's Name: <br />APPLICANT DECLARATION <br />I lrcrcby all-rm undcr penalty of perjury one of thc following dcclarations: <br />Demolition Pcrmits-Asbcstos Notilication Fedcral Regulations ('Iitle 40, Part6) <br />-Rcquircd <br />l*ttcr of Notihcation <br />-l <br />ccrtily thal the t'edcral rcgulations regarding asbcslos rcnxrvalrrc nol applicablc to this projcct. <br />-l <br />ccrtily that I have rcad this applicatkrn iutd statc that lhc inlirrnratiort is corrcct.with allCity and County <br />rlrdinanccs and Statc Laws rclating to buikling construction. <br />atxlve nrcntioncd pK)pcrty lbr insJrcction <br />Applicant 0r Agent <br />Penrrilcc nerrne <br />authorizc rcprcscntativcs <br />to <br />and <br />7 <br />ttt uprn tlrc <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 />Buildinq <br />Under Slab / Floor <br />Bondinq / Grounding / UFER z-Lrl-?1\L^, loa <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factorv Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rough <br />Ceilinqs [-Bar Rouqh) <br />Meter Release 2"tt-Zc a.\P t{, <br />Rouqh ?'?Y -Zr' I -#Service [\Ieter 7-?l-LD /'a-,,) <br />F!NAL ? -lo-fu ).f 7o., <br />Notes, Remarks, Etc