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ELECTRIGAL.I NSPECTOR RECORD <br />APPROVALS DATE lD/slG.GOMMENTS Owns-Buildd Dccluation <br />I hacby affim und6pcndty of pcrjury that I m cxmpt fm thc Contrrcon'Liccnsc Law for thc following rcuon (s@.7031.5 Buins <br />md Profssion Codc): Any City or Conty which rcquitc a pcmit to @nstruct, altcr, improvc, &molish or rcpair ily structurc, prior to its <br />isuurc, also rcquirc thc appliot fd such pcmit to filc a signcd Etat@mt that hc ff shc is licmscd pmuut to thc provisions of thc <br />Confe-tor's Licmcd L8w (Chapta 9, Cmmcing with Setio 7000 of Divisiff 3 of thc Bwins sd Prcfsiffs Codc) or thar hc or <br />shc is cxop thcrcfrcm ud thc bsis ftr thc allcgcd cxmprion .Any violarion of Scction 703 t . 5 by uy applicut ftr a Fmil subjccb thc <br />applicmt to I civil pflalty of not morc ths fivc hundrcd dollm (t500). <br />_1, c omo of rhc Fopcrty, or my mploye witb wags u thcir solc mpqralio, will do thc work md rhc smctw ir not intadcd <br />or offccd fc salc ( Se.70,14, Bwitre ud Prcfdims Cod!: Thc ConErctry's Lic@c Law dm not apply to u omr of the propcrty <br />who buil& or improve thcrcq ud who dG such wort hiruclf tr h6€lf 6 thrcugh his o hcr own cmploye, providcd tha! such <br />improvmqts e not intcndcd q offcrcd fo salc. If, howcva, thc building or improvoar is sold within onc yca of @mplction, thc <br />Owna-Builda will havc thc burda ofproving thar hc u shc not build q improvc for thc purpcc of salc). <br />_1, s owncr of thc prcpcrty, m €xclsivcly cmredng with limscd contrrcton to @nstruct thc prcjcct ( Scc. 7044, Bsinss md <br />Profsion Codc: Thc C-ntretor's Licsc lsv ds not apply to u ownq of prcpcny who builds q irnprovs thmn , md who <br />contrels fq such prcj@B wi$ 8 Contreto(s) licascd pmmt ro thc Cotrrctor's Liensc Law.). <br />_l un Section & P.C. for this reason. <br />Date: <br />I hercby affirm und6 pcnalty of pcrjury onc <br />_t havc md will mintain a CdtifiBtc of Crnscnt o SclfJnsurc for workc6' compcnsation, o providcd fa by Scction 3700 of lhr <br />Labor Codc, for thc pcrfmue of thc wqk for which thc pmir is issucd. <br />_l havc ed will mainuin wqkm' compemation iroume, a rcquircd by S4tion 3700 of thc Labq Codc, for thc pcrfommcc of thc <br />work for which ttis pqmit is iisucd. My wq&6' compqrsalion insurue cuia md policy nmbq sc: <br />f"#.,. <br />Policy Number Expires: <br />(This section nr or less) <br />{cettitythat in the pcrformancc of the work for which this pcrmit is issued I shalt not ernptoy Bny pcrson in any manner so as to <br />bccame subject to the workcrs ' compensation laws of California, and agrec that if I should bccomc subject to the workers' <br />of Scction 3700 of the Labor Codc, I forthwith comply with thosc provisions.. <br />Failurc to secure workers'coverage is and shall subject an employer to and civil <br />fincs up to onc hundrcd thousand dollars ($ 100,000),in addition to thc cost of compcnsation, damages as providcd for <br />the Labor Codc, interest and anorney's fees, <br />Scction 3076 of <br />LICENSED CONTRACTORS DECLARATION <br />I hcrcby aflim undo pcnalty ofpcrjury thar I m lienscd unda provision of Chapts 9 (commcncing wirh Scction 7000) of Division 3 of <br />thc Bwircs ild Profsions Codc, ud my liccnsc is in full fre od cffct. <br />Liccnse /-t ^...Liccnsc Numbcr <br />Date' Contractor: <br />W <br />I hmby afhm und6pcnalty of pojury thd thsc is a mtruction lodinS agocy fcthcpcrfoma@ of thc work forwhich this pcmit is <br />i$ucd (Se. 3097, Civ. C.). <br />Lad6's Nmc: <br />lrnder's Addrcss: <br />APPLICANT'S DECLARATION <br />Dcmolitio Pcmits-Asb6tc Notifi€tion Fc&ral Rcgulations (Titlc 40, PsIt 6) <br />_ Rcquircd L.tt6 ofNotificatim <br />I crniry thst thc fcdcral rcgularios rcgddinS abcsts rcmovd uc not 8pplicablc ro $is prcjcct. <br />{t **y tt.ttt rtc rud thir applicaio ed ststc u..t thc $ovc infmatim is cmcr t agr* ro ffiply with i.ll City dd County <br />ordinances and State Laws reluing ro building <br />above mentioned property PurPoscs. <br />and hereby authorizc rcprscntativcs of this <br />I <br />and to enter uPon thc <br />Site-Work <br />Underground / <br />Pole Bases ,L4- /T)1,/tUn l,fr ND <br />Lightg a*{/r/4"2 (L/-4/\;-..,- <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Eromunications Cablert <br />Building <br />Under Slab / Floor <br />Bonding I Grounding / UFER <br />Transformers <br />Torquing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soffit Rough <br />lings (T-Bar Rough) <br />Release <br />Rough <br />Service Meter -- ./,/, <br />FINAL ffi,<, <br />^))Notes, Remarks, Etc.J.\---l