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ELECTRICAL.INSPECTOR RECORD <br />[J r.'\(Jn <br />APPROVALS DATE !D/SIG,COMMENTS OWNER BUII,DER DELCARATION <br />I hcrchy aflirnl undcr Fnally of Frjury that I m crcmpt lhrm thc ConlractoF' Liccns Law for lhc following rcasrn (Sq:.7031,5 <br />Business ,fij Profession CGlc): Any City or County which rcquircs a Jf,mrit k, construct. ahcr. inrprovc, ,lcniolish or rcJuir uy <br />structurc. prior tr ils issuancc. also rcquires thc applicant for such lErmil kr lilc a signed slalenEnl that lE or shc is liccn$d puBuant <br />kr thc pruvisions of thc Contrnctor'r Liccnsd Law (Chaptcr 9. Commcncing sith Scction 7000 of Division -l of lhc Busindss and <br />ProlcssionsCodc)orthatheorshciscxcmptthcrcftomandthcbasislbrthcallcgcdexcmptiotr. AnyviolationofSe-tion7O3l.5byany <br />applicant lor a Jrmit subjccts thc applicanl lo a civil pcnalty of not morc lhan livc hundrcd dollars ($500). <br />_1. as owner of the propcrty. or my cmpl()yees with wagcs as thcir solc compcnsation. will do lhe wtrk and thc strul*ture ls not <br />intcndcd or oll'crcd tilr salc (Scc.7M4, Busincss and Prot'cssions Codc: The Contractor's l-iccnsc Law drrcs not apply lo an owncr of <br />thc pruJrcrty wlxr builtls or impn)vcs thercrrn. uxl who tftrcs such wort himsclf or hcrself rlr lhnrugh his or her own cmpk)yccs. <br />providcd that such impruvcmcnts arc n<lt intcndcd or oll'crcd lirr sale. lt. howcvcr, lhc huilding or impft)vcrncnl is sold within one ycar <br />ot'complctir)n, thc Owncr Buikier will have thc burdcn ot'pnrving that hc or shc did mlt buikl or improve thc pnrpcrty tirr thc purJx.rsc of <br />salc). <br />_1, as owner of the pr)pcrty. am cxclusivcly conlractfurg with liccnscrl conlracloni l() construct thc pnrjcct (Sec. 7044, Business <br />and Prufbsskrn Ctxlc: 'l'hc Contractor's Liccnsc Law docs not apply to an owncr of pnrJrcrty wh<l builds or improvcs thererln, <br />and who contracls lirr such pnrjects with a Contractor(s) licenscd pursuant to thc Contractor's Liccnse [-aw). <br />_l am cxcmpt B.lirr <br />I hcrcby al'l'irnr under pcnalty of pcrjury onc' of thc litlkrwing dcclaralions: <br />_lhavcarxlwill maintainaCertificateofConscnttoSclf-lnsuretilrworkcrs'cotnpcnsalion,as pnrvidedtbrbyScctitlnlT00ofthc <br />Labor Crxlc, lirr thc perlbrmancc of the work tbr which the pcrmit is issued. <br />_l havc and will mailrtain wrlrkcrs' contpcnsatiorr insurancc, as rcquiretl hy Scction 37()0 of lhe Labor Cotle, lor thc Jrcrlirrmancc ttf <br />tlrc work lirr which this pcrmit is issucd. My workcrs' compcnsation insurancc carricr arxl plicy numbcr are: <br />Policy Number: Expircs: <br />_l ccrtily thal in thc pcrlilrmancc of thc work lilr which this Jrcrnrit is issuctl, I shall not employ any person in any manncr <br />so as to h*-conrc subjcct to thc workers'comJrcnsalion laws of Calittrrnia. and agrec that it'l should bccomc suhjccl ttt the <br />workcrs' compcnsation pnrvisions o[ Scction 3700 of thc Lahlr Codc, I shall, tirrthwith comply with those provisions.. <br />WARNING: Failurc k) surc workcrc'compcnsation coveragc is unlawtirl. md shall subject an cnploycr t) criminal Fnaltics andt <br />civil f'incs up lo onc hundrcd thousantl tlollars (S to lhc cost comJrcnsation, rlamages as provided lor thc <br />Scction .l()76 ol'thc ilrtcrcst arrd <br />L <br />I hcrcby al'lirnr urrder pnalty ol'pcrjury that I anr licenscd untlcr pnrvision of Chaptcr 9 (commcncing with Scclion 7UX)) of Division -J <br />ol' the Busfurcss and Prol'cssions Codc. antl my licensc is in tirll tilrcc and cll'cct. <br />Liccnse Class: Liccnsc Numhcr: <br />Conlractor: <br />W <br />I hcrcby allirm under Fnalty of pcrjury that lhere is a constructkrn lcnding aScncy for thc lrcrfomcc of lhc work lbr *hich lhis 1Emit is <br />issucd (Se. 1097, Civ. C.). <br />[,c'nder's Namc: <br />lrnder's ArJrlrcss: <br />APPLICANT DECLARATION <br />I hcrcby atlirm undcr penalty ol'perjury onc of thc lirlkrwing dcclarations: <br />Dcnxrlition Pcrmits-Asbcstos Notification Fcdcral Regulations (Titlc 40, Part6) <br />_Requircd lrtter of Notitication <br />_l ccrtily that thc l'cderalrcgulations rcgarding asbeslos rcnxrvalare n()l applicablc to tltis prrrjcct. <br />_l cerlity that I havc rcad this and statc that thc ahrvc inlirrmation is correct. I agrec lo conrply with all City and County <br />ordinanccs and State Laws rclating <br />atxlvc mentioncd propcrty lbr <br />Applicant or <br />Penrrilec nnme <br />conslruction. ail hcrehy auttmrzc rcprcsentat ivcs <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Lite Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bonding I Groundins I UFER <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 Rouqh) <br />Meter Release <br />Rough /24"1 q fL. z, <br />Service lMeter I <br />FINAL atn\w Dnn^n n.*Tt <br />Notes, Remarks, Etc I [\- <br />,