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ELECTRICAL-INSPECTOR RECORD <br />f)^'. nO n7 Dn{ H <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby aftirm undcr pcnolty of JErjury lhal I m exempl frum thc Contraclors' Licensc law for rhc following rcarcn 1Sa.7031.5 <br />Busincss ard Profcssion Codc): Any City or Couoly which rcquircs a pnnh to construcl. aher. irnprovc. dctr[lish or rcpair my <br />structure, pior to its issuonce, slso rcquircs Ihc opplicatrt for such Jrcrmit to filc ! signcd statcment that he or shc is licensd pumuant <br />to the Fovisions of thc Contmctor's Liccnscd [aw (Chaptcr 9. Commncing wilh Scclion 7000 of Division .l of thc Busincss rnd <br />PmfcssionsCodc)orlhathcorshciscxcmpllhcrcfronundthcbtrsirforthcdllcgcdcxcn[lior. AnyviolotionofSNtkilT0.ll.5byany <br />rpplicant for a lrcmil subjccts thc applicanl lo a civil pcnally of not rrcrc lhdr five hundrcd dolles (Ssfi)). <br />_l.as owncrol'thcpropcrty.ormycntployceswithwagesastheirsolccornpensalion.willdotheworkandthcslnK'lurcisnol <br />intcndcd or ollcrcd lor salc (Scc.7044. Busincss and Prof'cssions Codc: Thc Contraclor's l-iccnsc Law drrcs not apply to att owncr of <br />lhe prcperty who builds or irrq)roves thcrcon. alrd who does such work hirnself or hcrsclf or lhrough his or hcr own cnlployccs. <br />providcd that such inrprovonents arc not inlcndcd or olTcred firr salc. lt. howcvcr. thc building or imp()vcrrcnl is s<lltl wilhin onc ycar <br />of cornphtion. thc Owncr Buildcr will havc thc burdcn of provirrg thut hc or shc did not build or inrprovc thc pnrprty lirr tlrc purfnsc of <br />salc). <br />_1. as owner of thc p()pcrty. am exclusivcly conlracting with liccnscd contractors to conslruct the project (Scc. 7(H4. Busincss <br />and Profcssion Codc: 'l'hc Contractor's Liccnsc Law docs not apply lo an owncr of propcrly who builds or irttprovcs thcrcon. <br />antl who contracls lbr such projects with a Contractor(s) licenscd pursuant to thc Conlractor's Liccnsc Law). <br />-l <br />arn Ior this reason. <br />) <br />I hcrcby affirrn undcr pcnalty of perjury onc ol'the ltrllowing <br />_l have and will maintain a Certitlcatc ol'Consent to Sclf-lrrsurc ftrr workcls'conrperrsation. as provided lirr hy Scctiort 3700 of thc <br />l;rtxlr Codc. for lhc pcrtbrnuncc of thc work f'or which thc pcrnrit is issucd. <br />_lhaveandwill nraintairrworkers'cornpcnsationinsurancc.as rcquircdhyScclion-17(X)ol'thcLaborCodc. lirrlheprcrtbrnranceof <br />thc work for which this pcnnit is issucd, My workcrs' conrpcnsation irrsurance carricr an<l grlicy nurttbcr arc: <br />Policy Number: Expircs: <br />_l certily that in the Jrcrformance of the work tbr which this perrnit is issucd. I shall not cnrploy any lrcrson in any tnanncr <br />so as to beconrc subjcct lo lhc workers'compcnsation laws of Calilirrnia. and agrcc thtl if I should bccortrc subjcct to tltc <br />workcrs' comJrcnsation provisions of Scction 37fi) of thc Latnr Codc. I shall. forthwith cornply with thosc provisiorts.. <br />WARNING: Faiturc lo sccurc workers' corrrpcrrsntion covcragc is urrlawf'ul. arrcl shall subjcct an crttploycr lo .rirrri,rrl-lrcnaltics and <br />civil fincs up to onc hundrcd thousand dollars ($1(X).ffiOt. in tddition to thc cost of conllrcnsation. danngcs as providcd for thc <br />a <br />I hcrcby alfirnr undcr pcrrulty of pc{ury lhat I anr licensed 9 (conrnrcncing with Scction 7000) of Division 3 <br />of the Business arrd Professions Codc. arxl rny liccnse is in lhll tirrce and ctl'ccl. <br />l.iccnsc Nulnbcr: <br />Dale:Conlraclor:_ <br />W <br />I hcrcby amrm undcr lEnalty of Frjury lhal thcrc is a onstruclhn hrxling {gcrcy for thc lrcrformrcc of thc work fur uhich rhis tmit is <br />issucd (Sa. 3(x)7, Civ. C.). <br />lrndcr's Namc: <br />Lcntlcr's Addrcss: <br />APPLICANT DECLARATION <br />I hcreby affrmundcr pcnalty of perjury one ol'thc folkrwing declarations: <br />Demolition Permits-Asbcstos Notification Fcdcral Regulations (Titlc 40. Part6) <br />-Required <br />Lettcr of Notificalion <br />-l <br />ccrtify lhat thc fcdcralrcgulations rcgarding asbcstos rcrlroval arc not applicablc to this projcct. <br />-l <br />ccrtity that I have read this application and statc that thc ahrvc irrltrrrnatiorr is corrccl. I agrc.e lo conrply with all C--ity and County <br />ordinanccs and State l-aws rclating to building constructiorr. and hcrchy iu{horize <br />atxlvc mentioned proprly ltrr <br />Applicant or Agent <br />l'crrtrilt'e nanle (;rrilrl ):z LS <br />Site-Work <br />Underqround <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltase <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <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 />Wails (Roush) <br />Ceilings (Hard & Soffit Rouqh <br />Ceilinqs [-Bar Rouqh) <br />Meter Release <br />Rouqh <br />Service Meter , <br />FINAL /Qrk)tb t4 6 (b//^^-rr <br />Remarks Etc <br />I <br />I --- <br />Y a sJ