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ELECTR ICAL.I NSPECTOR R ECOR D <br />r\() ,17 <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION <br />I hcrcby aflirm undcr Fnally of trcrjury lhal I am cxempt fmm lhc Contraclom' Licen* tiw for lhc following rcarcn (Scc.70ll) <br />Busincss and Profcssion Codc): Any Cily or County which rcquircs a ff,rmil to @nsIruct. alts. imprcvc, dcmlish or rquir any <br />structure. prior lo ils issuance. also requircs lhc applicant for such Frcrmit to lilc a signcd stalcmnl thal hc or shc is liccnsd pu'rsuant <br />to thc prcvisions of thc Contractor's Liccnscd law (Chaptcr 9. Commcncing with Scction 7ff0 of Division 3 of thc Business and <br />ProfcssionsCodc)orthsthcorsheiscxcmptthcrcfromondthcbosisforthcallcgcdexemption. AnyviolationofsctbnT0.ll.5byany <br />applicsnt for a pcrmit subjels thc spplicunl lo { civil penally of not rn)rc lhon fivc hundrcd dollors ($500). <br />-1. <br />as owncr of thc property. or my employecs with wagcs as thcir solc compensation. will do thc work and the stnrcturc is ff)t <br />intendcd or ofl'ered lbr salc (Sec.7B4. Busincss and Professions Crxlc: Thc Contractor's Liccnsc L.aw does not apply to an owncr of <br />lhc propcrty who builds or improvcs thcrcon. arxl wtro docs such work himsclf or hcrself or through his or her own employccs. <br />provided that such improvenrcnts arc rmt inlerxlcd or oftbred for salc. lf. h<lwcvcr. thc buihing or improvenrcnl is rcld within onc ycar <br />of cornphtion. lhc'Owncr Buildcr will havc thc burdcn of proving that hc or shc did not build or improvc thc propcrty for thc purprsc of <br />sale). <br />-1. <br />as owncr of lhc propcrty. anr cxclusivcly conlracting with liccnscd conlractors to conslrucl lhc projcct (Sec. 7W, Busincss <br />and ftotbsskln Codc: Thc Contractor's Liccnsc Law docs not apply to an owncr of prolrcrty who huilds or improvcs thcrcon. <br />and who contracts ltlr such projccts with a Contracto(s) liccnscd pursuanl lo thc Contractor's Liccnsc kw). <br />-l <br />arn cxcnrpl undcr Scction-. B. & P.C. lirr this rcason. <br />Date:-Owner:_ <br />WORKERS' COMPFNSATION <br />DECLARATION <br />I hercby affinn undcr pcnalty of pcrjury orrc ol'the firllowing declarations: <br />-lhavcamlwill <br />maintainaCcrtificatc<lfConscnttoSclf-lnsurcftrrworkcrs'compensalion.as providcdforbyScction.lTfi)ofthc <br />Labor Ccxlc. for thc pcrformancc of the work for which the permit is issucd. <br />_l have and will rnnintain workcrs' compcrrsation insurancc. as hy Scction 37fi) of thc Labor Code. for the performancc of <br />carricr and plicy nurnbcr arc:the work frrr which this pcrmit is issucd. My workcrs' <br />Policy <br />_l ccrtity that in thc Jrcrformancc o[thc work for which this permil is issucd. I shall not cnrploy any lrcrson in any manncr <br />so as lo bcconrc subjcct to thc workers'conrpcnsalion laws of California. and agrcc thal if I should bc'come subjcct to the <br />workers' cornpcnsation provisions of Section 3700 of the [:tnr Codc. I shall. forthwith comply with thosc provisions.. <br />WARNING: Failurc lo sccurc workcrs' cotrrpcrrsation covcragc is urrlawt'ul. and shall suhjccl an cnrploycr to criminal pcnaltics and <br />civil fincs up lo onc hundrcd thousand dollars ($lffi.fiXll. in addition to thc cost of compcnsation. danugcs as providcd lor the <br />,:l1"'?r (*arrd attorney's fees. <br />Applicant: <br />I hcreby allirm undcr Jrcnalty of pcrjury lhat I arn licenscd undcr provision of Chapter 9 (conrnrcncing with Section 70m) of Division 3 <br />of thc Busincss and Professions Codc. and rny liccnse is in l'ull frrrcc and clTcct. <br />Liccnsc Nurrrhcr:\o"38o\t <br />) <br />W <br />I hercby affirm undcr Jrcmlty of Frjury thut lhcrc is a constructk n lcnding agcncy for lhe JErfomre of Ihc work for which lhis Imit is <br />issued (Sa. 3097. Civ. C.). <br />kndcr's Namc: <br />Lcndcr's Arldrcss: <br />APPLICANT DECLARATION <br />I hcrcty atlinn undcr pnalty of pcrjury onc of the following dcclarations: <br />Demolition Pcrnrits-Ashcstos Notification Fcdcral Rcgulations (Titlc 40. Parl6) <br />Rduircd lrtrcr of Nolifi cdion <br />-l <br />cedity that the fcdcral rcgulations rcguding ssbestos rcmval re not rpplicabh to thls prejert. <br />-l <br />cedify thlt I have rcad this applicalion 8rd stste lhat the abovc infomtion is corel. I agrc to omply wilh all City and County <br />ordimres and Ststc hws rchring to building conslructiotr and hcrcby authorizc rcpEsnhliws of this Cily and Couily to cnts upon the <br />atxlvc nrcnlioncd propcrty for insJrcction purF)scs. <br />Applicant or Agenl <br />I'ernritee nnme ( prinl ): <br />,,r",-//nf t\ <br />Site-Work <br />Underqround <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 />Building <br />Under Slab / Floor <br />Bondinq I Groundinq / UFER <br />Transformers <br />Torqueinq <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 Rouqh) <br />N/eter Release <br />Rough '1 ll\/t<t sb 6q <br />Service lVleter '^ / t ^t/-/.9 <br />FINAL 7/"1 lA(Ururru M6J <br />Notes Etc. <br />Class: . B Liccnsc <br />,,r", -7 11 fl\conrracro., \\cnn€- GSC <br />G-