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ELECTRICAL-INSPECTOR R ECORD <br />nof <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby alfum undcr pcnalty of pcrjury that I am cxcmpt from lhc CotrtracloN' Liccns Lnw for lhc following rcasn (Str.70.11.5 <br />Busilc$s and Profcssion Codc): Any City or Counly which rcquircs a ,Ermit to conslrucl. allq, improve. demlish or rcpdir any <br />structurc. prior lo its i$suure, also requircs thc a0plicant for such frcrmil to lile a signcd stalcmnl that hc or $he it liccnsd pursuant <br />lo lhc pmvisions of thc Contractor's Licenscd Law (Chaptcr 9. Comrencing with Scction ?000 of Division 3 of thc Busincss and <br />ProfessionsCodc)orthttlrcorsheisexcmptthcrcfromandlhcbasisforthcallcgcdexcmption. AnyviolalionofS@tion70.1l.5rbyany <br />applicant for a pcrnrit subj$ls lhc applicant to s civil pcnalty of not [prc lhan fivc hundrcd dollats (5500]. <br />-1, <br />ils owncr of lhc proFny. or nly employccs with wagc$ as their srlc compcnsalion. willdo thc work a[d thc slrulre is mt <br />intcndc{t oroffcrcdforslc(Ss.T044.BusincssandPrcfcssionsCodc:ThcConlractor'sLicc.scllwd@snotapplylomownerof <br />thc pmFny who builds or imprcws thcmn. ntd who dms such work himsclf or hcrslf or thrcugh his or hcr own cmployccs. <br />providcd lhnt $uch hnJrmvctmnts arc ml intcndcd oroffcrcYl for slc. lf. howcvcr. lhc building or imprcrcmnt is $ld within onc )tu <br />of comphion. rhc Owncr Builds will haw rhc hurdcn of proving tluil he or shc did mt huiH or impmw lhc pmlEly for lhe purfns of <br />sah). <br />_1. as owncr ol'thc prof,crry, anl cxclusively conlraclirrg with liccnscd contractors lo conslruct lhe projcct (Scc. 7044. Busincss <br />and Pnrfcssion Code: The Contractor's Licclrsc Law docs not apply to an owncr ol prolrcrly u'ho builds or improves thercon. <br />and who contracls for such projccts with a Contraclor(s) liccnse'd pursuant to thc Contractor's Liccnsc Law). <br />_l arrr cxcrnpl undcr & P.Cl.rcil \( ) ll. <br />Drr".S,2L n <br />I)l':('L,\ R,\'l'l( )N <br />I hereby affirm under pcnalty of pcrjury onc of the folklwing dcclarations: <br />_l have and witl maintain a Certificate of Consent to Sclf-lnsure fbr workers' compensation. as provided for by Section 37fi) of the <br />Labor Codc. for the performance of the work for which the pernrit is issued. <br />_l have and will maintain workers' compensation insurance. as rcquircd by Scction 3700 of the [:bor Codc. for thc performance of <br />the work for which this permit is issucd. My workers' compcnsation insurance carricr and plicy number are: <br />Policy Number: ExPires: <br />_l ccrtify that in tlrc pcrt'orrnancc ot'thc work for u,hich this prnrit is issucd. I shall nol entploy any pcrson in any nranncr <br />so as lo bcconrc subjcct to thc rvorkers'colrrpclrsalion laws of Califrrrnia. lntl agrce lhat il'l shttuld bcconrc subjcct lo tlrc <br />workcrs' cornJrcltsation provisions of Sccti<ln 37fi) of the Lrkrr Cloclc. I shall. f<rrthwith conrply wilh thosc provisions.. <br />WARNIN(}: Failurc lo sccurc u'orkcrs'covcragc is unlawtirl. arrd shall sub.icct an cntptoycr to crimi?al pcnalties and <br />civil fincs up lo onc hurtdrcrl thousaltd dollars irt arltlitiort to thc cost ol'damages as provided for the <br />aScclion lo7(r of lhc Labor Ctxlc. itrlercst and l'ccs. <br />o^ <br />I)Ii( I,AR,\I ION <br />I hcrchy all'irrn untlcr pcnalty ot'pcrjury that I arn liccrrscd undcr provision ol'Chaptcr t) (comttrcncing u'ith Scct ion 7m0) of Division 3 <br />ol' the IJusiness and Prol'cssions (lodc'. and rny liccnsc is irr lull lirrcc trd cll'cct <br />Liccnse Class: Liccnse Nunrbcr: <br />Date:- Contractor: <br />C()NS'I'I{U(:'I'ION I,I.]N I )IN(; A( ; IlNC\' <br />t hcrchy aflirm utrdcr Frcnallyof pcrjury rhot thcrc is a constructiotr hrding rgcncy lor lhc pcrforrorcc of lhc work for which this ttrmit is <br />issucd (Scc. 3097. Cir'. C.). <br />Irndcr's Nanrc: <br />[.cntlcr's Acldrcss: <br />APPLICANT DECLARATION <br />I lrreby aflirm undcr pcnalty of perjury one of the following declarations: <br />Dcrnolition Pcrmits-Asbestos Notification Fcderal Rcgulations (Title 40. Part6) <br />-Rcquircd <br />lrtter of Nolification <br />-l <br />ce.tify that thc fcdcralrcgulstions rcgurding asbcslos rcmval ue not applicablc to this pmject. <br />_l ccnify that I havc rcad rhis applicglion atd slatc th81 rhc stnve infirnmtion is corct. I agre to conrply with all Cily snd Coutrly <br />ordindnces and Statc L8ws rchlingrrfauilding construction. and bcrchy autluizc rcFcsentalives of this Cily 8nd Counly to enlq u[nn thc <br />vi:x: <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 Sl ab I Floor <br />Bonding I Grounding / UFER /o4a-/c ,Ea/a <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 />Ceilings (Hard & Soffit Rouqh <br />Ceilinqs [-Bar Rouqh) <br />Nleter Release /a")-/e ,iB.,l?r-5 <br />Rouqh <br />Service Meter /0291 'fulat -/1 <br />FINAL lV'19- lh ,i\rb(r^1eP tty <br />Notes, Remarks, Etc rru\ <br />)/\i I