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ELECTRICAL.INSPECTOR R ECORD <br />on{ tr <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUTLDER DELCARATION <br />I hcrcby afftrm undcr Jrcnahy of rErjury that I en cxcmpt from thc Contractos' Liccns kw for lhc followilg reasn (Stc.7031.5 <br />Busincss md Prcfcssion Codc): Any City or County which rcquircs a prmit to construcl, altcr, improvc, dcmlish or rcpair any <br />struclw. prior to its issuare, also rcquircs thc applicilt for such tEmit to ailc a sigmd statcrent thal lE or slrc is lien$d puNanl <br />lo thc pmvisions of thc Contractor's Liccnsd kw (ChBptcr 9. Cormercing with Scction 7000 of Division 3 of the Busircss and <br />PmfcssionsCodc)orthathcorshciscxemptthcrcfromandthcbasisforlhcallcgcdcxcmption. AnyviolationofsrclionT03l.5byany <br />applicant for a lErmit subjccts thc applicant to a civil penalty of not mrc thatr fivc hundrcd dollss (S500). <br />-1, <br />as owncr of thc propcrly, or my cmployccs with wagcs as thcir sole compcnsation, willdo thc work Bnd the structurc is not <br />intcndcd or offcrcd for sale (Scc.704+. Busincss and Professions Code: Thc Contractor's License [:w docs not apply to an owner of <br />the property who builds or improvcs thercon, and who does such work himsclf or hersclf or through his or her own cmployecs. <br />providcd that such improvcrncnts arc not intcnded or offcrcd for salc. lf. howcver. thc building or hnprovcnrnt is sold within onc )rar <br />of cornpletion. thc Owner Buildcr will havc thc burdcn of proving that hc or shc did not build or improvc thc proprty for thc purynrc of <br />sale). <br />-1. <br />as owner of thc property, am cxclusivcly contracting with liccnscd contractors to construct thc prqcct (Scc. 7W, Busincss <br />urrd Profcssbn Codc: Thc Contractor's Liccnsc Law does not apply lo an owner of property who builds or improves thereon, <br />and who contracts for such projccts with a Contractor(s) liccnscd pursuant to thc Contractor's Licensc Law). <br />_l am cxcmpt undcr Scction_, B. & P.C. for this reason. <br />f).rlo. <br />WORKF''ITS' COM PENSA TION <br />DF'CI ^ RATION <br />I hereby affirm under penalty of perjury one of thc following declarations: <br />-l <br />have and will maintain a Certificalc of Consent to Self-lnsure for workers' compcnsation, as providcd for by Section 3700 of the <br />Labor Codc, for thc pcrformance of the work for which the pcrmit is issucd. <br />-l <br />havc and will maintain workers' compcnsation insurancc, as required by Section 3700 of the Labor Codc, for the Srrformancc of <br />the work for which this permit is issued. My workers' comlrcnsation insurance carricr ud plicy number are: <br />e C^ <br />Lo [,lzll'olicy (; <br />-l <br />ccrtify that in the lrcrfornuncc of thc work for which this pcrmit is issucd. I shall not entploy any pcrson in any manner <br />so as to bccomc subjcct to thc workers'compensation laws of California, and agrce that if I should bccome subject to thc <br />workcrs' compcnsation provisions of Scction 3700 of the [:tnr Codc. I shall, forthwith comply with thosc provisions.. <br />WARNING: Failurc to securc workcrs'conrpensation covcragc is unlawf'ul, and shall subjcct an cmploycr to criminal lrcnaltics and <br />civil fincs up to onc hundred thousand dollars ($100,0001, in addition to thc cost of conrfrcnsation, damagcs as providcd lirr thc <br />cattorncy's l'ccs. <br />DFCI-ArIATI0N -r <br />I hcrcby aftirrn undcr yrcnalty of prjury that I am licenscd under provision of Chaptcr 9 (comrncncing with Scction 7m0) of Division 3 <br />of thc Business and Profcssions Code, and my license is in full force and cffcct. <br />Liccnse t Nur.trcr:- { t{ S72O <br />Drt", ? UlTg f 2( conrracror,* TP <br />W <br />I hcrcby alfrm under pnalty of pcrjury Ihal thcrc is a conslructirn hnding agcncy for lhe psformncc of thc work for which this JEmil is <br />issucd (Scc. 3@7, Civ. C.). <br />lrndcr's Namc: <br />[.cnder's Address:F <br />APPI ICANT NECLARATION <br />I hcreby affirm under penalty of perjury one of thc follorving declarations: <br />Demolition Permits-Asbcslos Notification Fcdcral Rcgulations (Title 40. Pafl6) <br />_Requircd l.cttcr of Notification <br />D <br />-l <br />ccnify thst thc fcdcrrl rcgulstions rcgtrding sbestos rcmvrl arc not applicsblc to this prcF. <br />Wccrtify *rtl havc rcad this application and statc thst thc sbovc inforrolion is corect. I 8grc to comply with all Ciryand Counly <br />ordimnces rnd Statc lrws rclsting to building coNruclion, and hcrcby authoria rcprcsnlativcs of this City snd County to cnlcr uIDn thc <br />abovc nrcntioncd propcrly for inspection <br />Applicant or Agent <br />Permilee name ( <br />x _ Dale:aa u l"sl zl <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab I Floor <br />Bonding I Groundinq / UFER <br />Transformers <br />Torqueinct <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 />N/eter Release <br />Rough <br />Service JVIeter tl .t // <br />FINAL )5l1rl I)AZ{TU <br />Notes, Remarks, Etc rl <br />no] r.r