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ELECTRICAL.INSPECTOR R ECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUI!.DER DEI,CARATION <br />t hcroby allirm undcr Fnahy of Frjury that I m crcmpt lil)N the Ciutrachn' Liccnsc Law tirr thc tbllowin! reas)n (Scc.70.ll.5 <br />Business aBl Protbssbn Grlc): Any City or County which rcquircs a lrmril to conslruct, altci improvc, rlcmlish or rcpair any <br />struchrc, [ri(]r k) ils issuarEc, also rcquircs lhc {pplicanl ti)r ruch [Ermit kr lilc a signcd stalcmnl that hc or shc is licctrscd pursuoil <br />k) lhc pruvisi{)ns of thc Conlractor's Liccnrcd Law (Chapler 9, Qommcncing wilh Scction 7U)0 of Diviskrn .l of thc Busincss and <br />P(rlcsskrns Grdc) ([ lh{t hc or shc is cxcmpt thcrclr}m and lhc hasis lirr lhc allcgcd ercmption. Any violation of Sstion ?0-l I .5 hy any <br />applic{nt li)r a Frmit suhjccls the applicart to a civil pcnally (rf not nnrc lhil livc hundrcd 'lollrrs (S5U)). <br />_1. as owncrol'thc pr"opctly, or nlycrnpk)yecs with wagcs as thcir solc conlp!'nsali()n. willdo thc work:rnd the slntclurc ls not <br />ilrlclrdcd or oll'crctl lirr salc' (.Scc.7044. Ilusincss alrtl Prlt'cssions CrxJc: 'l'1rc Contracl()r's Liccnsc [-aw tftrcs not apply to an owttcr ttf <br />llrc'pnrlxrly wlxr builds ()r impn)vcs lhcrcrln. anl wlur tkrcs such wort< hinrsc'll rlr hcrsc-ll'or lhrough his or hcr own cmpk)y(-c-s. <br />ot'conrplction, llrc Owncr Buildcr will havc the burtlcn ot-pnrving lhal hc or shc'ditl rxrl huild rlr improvc' llrc pntprly lirr thc purJxrscol' <br />saL'). <br />_1. asowncrol'lhe pr)lrcny. anrcxclusil'elyconlracting with liccnse-tlconlnrckrrstoconslnrct tlrc pro.icct (Sc'c.7(),14, Btrsincss <br />antl Pnllbssion Cotlc: 'l'hc Contractor's l.iccnsc l-aw tkres lttlt ap;lly t() an ownr'r <lt'propcrly who huilds or imprrtvcs thcrcolt. <br />and wlro colrlracls firr such projccls with a Conlraclor(s) liccnscd pursuanl lo thc Cirntraclor's l.iccnsc Law). <br />-Iantc.xcnlplttndcrS..clirltt-.t].&I,.C.lilrlltisrcitsrltt. <br />I)nle: Owner: <br />lVORKERS' COI\I PENSATI(IN <br />DECLARATION <br />I lrt'rchy al'l'irrn urrdcr pcnalty ot'pcrjury onc ot'thc ftrllowing tlcclaratiorrs: <br />_lhavcamlwill mainlainaCcrtilicatcol'ConscrrttoScll'-lrrsurctilrworkcrs'contpcnsalion.as providedlilrbyScctiott.lT(X)ofthc <br />Latxrr Crxlc. lirr thc pcrfirrnuncc ol'llrc work frlr which thc Jrcrmit is issuetl. <br />lhc work tirr which this prnrit is issucd. My worke-rs'compcnsaliolr insuriurcc carrier antl ;xrlicy nutttbcr iu'c: <br />Policy <br />_l ccrtity lhal in lhc 1^*rlirrmance ol'thc work tirr which this pcrnrit rs issuc'd. I shtll nol cntpkry any F-rson in any milnnL'r <br />so its to hccorrrc suhject lo lhc workcrs'compcnsalion laws ol'Calitornia, and agrcc lhrtl il'l shoultl hcconrc suhjcct to thc <br />workcrs' conrJrcnsation pnrvisions ol'Scction l7(X) ol'lhc Lahrr Crxlc. I shall. lirrrhwith conrply with thosc prtvisions.. <br />WARNTN(l: Failurc to sccurc workers' comp^*nsirtion covcragc is unlawlirl. and shall suhject an cmploycr to crinrinal pcrraltics and <br />civil I'incs up to onc hundrcd thousalrtl dollars ($l(D.()([)). in addition lo lhc cosl ol'conrpensalion. damagcs as provirlcd lirr thc <br />Scclion 3076 ot'lhc Lalxlr Crxle, intcrcsl and attorncy's l'ccs. <br />l)ale: <br />LICENSED CONTRACTOR <br />DECLARATION <br />I hc-rcby aflirnr undcr Fnalty ol'prcrjury lhat I arn liccnscd unde'r pnrvision ol Chapter 9 (comrrcncirrg with Scctkrn 70m) rtl'l)ivision .l <br />o[ thc Business and Pnrfcssions Cotlc, anrl my liccrtsc is in titll tirrcc and cll'cct. <br />I.lt'cnsc'Ntt nrhcr:3o <br />I tct <br />W <br />I hcrchy atlllm undcr lrcndty of Frjury th{t therc is a construclion btuling aSency for thc lrcrli)mancc (rf thc work itr which lhis lsmit is <br />issucd (Scc. -1097, Civ. C.). <br />IJndcr's Nanrc: <br />lrntlcr's Addrcss: <br />API'LICA NT DECI,ARAI'ION <br />I lrcr.*hy allirrn untlc-r Jrcrralty ol pcrjury ottc ol'lhc lirlkrwing dcclaraliotrs: <br />l)c-nxrlition Pcrmils-Asbcslos Notilicalron l;cdcral l{cgulations ('l'itlc 40, [)trl(r) <br />_Re-qu ircd lrltc'r ol' Nrililication <br />_l ccrtil'ylhal thc l'crlcrllrcgulaliorrs rcgarding aslx'slosrcnxrvalarc nol tpplicahlc lo lhis projccl. <br />_l ccrtily lhal I havc rc-atl lhis application and slatc lhal lhc ahrvr.'wrth :rll ('ity arrrl (irurrlv <br />rlrdinanr:e's :urd Stalc Laws rclaling to huilding conslntctirln. antl and c0unty to enl('r uprn lhc <br />abovc rncrrtiorrctl pr1)pcrly tirr ilrspcction t)urlx)scs. <br />Applicnnt or Agenl <br />Perrrrilee lralrx'( <br />,r^r, G/fdfi <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 / Floor <br />Bonding I Grounding I UFER <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soffit Rouqh <br />Ceilings [-Bar Rouqh) <br />lVleter Release <br />Rouqh <br />Service N/eter _1, I /.r-/-av-A <br />FINAL ab/al utLf,w /aoq w <br />Notes, Remarks, Etc.JJ <br />1 <br />lYlrl (tZ-O.