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ELECTRICAL.I NSPECTOR RECORD <br />r")0 n'7 <br />APPROVALS DATE !D/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hac$, affm undr pemlty of perjury that I m cxcmpt from thc Contrsctoc' Licme Law for thc following rcun (Se.70-11.5 <br />Bsio6s ud Profsion Codc): Any City or County which rcquirc a pamit lo consiruct, alta. improve danolish or rcpair uy <br />structuq Fk)r to its issuacc. aho rcquirG thc applicet for such pcrrnit to filc a signed ststddt that hc or she b licdEcd plmot <br />to thc prcvisioru of the Contractor's Liccnsed taw (Chapt6 9. Commmcitrg with Setion 7000 of Division 3 of thc Bsins od <br />PmfsionsCode)qthathcorshciscxmptthq€fromudthcbasisforthcallcgcdcxmption. AnyviolationofS6{ion70ll.5byany <br />applicant for a pcrmit subj*ts thc applicanl to a civil pmlly of not morc thu livc hundrcd dollm ($500). <br />-1, <br />s oma ofthe prcperty. or my cmployc with wags re thcir mlc compcnsaion. will do thc wort ad thc stnrclrc b not <br />intodcd or ofrercd for el€ (56.7044. Busins ud Profsiom Codc: Thc Contractor's Licw law doc not 4ply to u omo of <br />thc popgty who builds or hnprcrc thc@n, ud who do6 such rrcrk himself or hdf or thrcugh his or ho om employrcc, <br />providcd that such imprcvqmts rc not intodcd oroffqed for sle. If, ho\q6. the buildirg or imprc@cnt is sld within onc )ry <br />ofcompletion. the Ownq Buiklcr will have thc btudo ofprcving tha he or shc did not build or imprcrc thc prcpsty for thc purpor of <br />eh). <br />-1. <br />c omer of thc propaty. m cxclusivcly contracting with licmcd contraclorc to corutruct thc projet (Ss. 7044, BBinG <br />md Profi=sbn Codc: Thc Contractor's Liccnsc Law do6 not apply to u owna ofpropoty who builds or improv6 thq@n, <br />and who ootmcis for such projers with a Contncto(s) licqE€d puB@t to thc Contrsctor's Licme law). <br />_l arn exempt under B. & P.C. for this reason. <br />I hereby affrm under penalty of pcrjury one of the follorving declarations: <br />_l have and will maintain a Certifrcate of Consent to Self-lnsure for work€rs' compensation. as provided for by Section 3700 of the <br />Labor Code, for the performance of the work for which the permit is issued. <br />I have and rvill maintain workers'-i700 of thc l-abor Code, for the performance o[ <br />the work for rvhich this pcrmit is and policy number are: <br />v0t t ^y6Ilxpires:o ? <br />Policy <br />_l cerrifu that in the perforrnance of the work for rvhich this permit is issued. I shall not employ any person in any manner <br />so as to become subject to the $'orkers' compensation laws of California. and agree that if I should become subject to the <br />workers' compensation provisions of Scdion 3700 of the Labor Code. I shall. forthu'ith comply \t'ith those provisions..I <br />WARNING: Failure to serure *'orkers' conlpensation coverage is unlawful. and shall subject an employer to criminal peflalties and <br />civil frnes up to one hundred thousand dollars ($100.000). in addition compensation. damages as provided for the <br />Section 3076 of the Labor Code. interest and attorney's fees. <br />I I <br />DI.,('LAIIA'I I()N <br />t hereby affirm under penalty of perjury that I anr licensed under provision of Chapter 9 (cotnmencing rvith Section 7000) of Division 3 <br />of the Business and Professions Code. and rny license is in full force and eflect. <br />License .,.*' C I 0 <br />('ontraclor: <br />('ONS'l'RU(11'tON LENDING A(;11N('\' <br />I hceby affm undr poalty of p€rjury that th6c is a congruaion loding agocy for the pofomcc of thc work for which this psmil is <br />issued (Sec. 3097. Civ. C.). <br />I-ender's Name: <br />APPLICANT DEC LARA'I'ION <br />I hoeby aftirm under penalty of perjury one of the following declarations: <br />Demolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) <br />_Required Letter of Notification <br />-l <br />cerri$r that the federalregulations regarding asbestos removalare not applicable to this project. <br />-t <br />cenify that I have read this application and state that the above <br />ordinances and State Larvs relating to <br />above mentioned property for <br />Applicant or Agent Signature: <br />Permitee nrme f printl, {d(e-','s(. <br />the <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas. Poo!, Fountains <br />Signs (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm I Dampers <br />Communications Cable <br />Buildins <br />Under Slab / Floor <br />Bondinq I Groundinq / UFER <br />Transformers <br />Torqueing <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 />Meter Release <br />Rough ll"Ztetl n <_z') <br />Service Meter <br />-\FINAL ll ,zt . l7 lLc tgt )3.62)314n / <br />Notes, Remarks, Etc \----.- <br />Lender's Address: <br />o