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ELECTRICAL-INSPECTOR R ECORD <br />Dr.,, nC) n7 Onl tr <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUTLDER DELCARATION <br />I hcrcby affirm undcr Fmlty of pcrjury that I an cxcmpt from thc Contracto6' Liccn$ ljw for the following rca$on (Ss.7031.5 <br />Busincss ard Profcssion Codc): Any City or County which rcquircs a lmmit to construct, altq, imprcvc, dcmlish or rcpair mf <br />struclurc, prior to its issuarcc, nlm rcquircs thc applicanl for such Jrrmit to filc o signcd statcrcnt thst hc or shc is liccnsd pursulnt <br />to thc previsions of thc Contraclor's Liccnrcd tiw (Chaptcr 9. Commncing wilh Setiotr 7000 of Division 3 of thc Busincss ed <br />PmlbssionsCodc)orlhathcorshciscxcmplthrcfromondthcbasisforthcallcgcdcxcmption, Anyviolntionofs$tknT03l.5byany <br />applicont for s pcrmit subjccts lhc applicant lo a civil pcnalty of not mrc than fivc hundrcd dollus ($500). <br />-1, <br />as owncr of thc propcrty, or lny cmployccs with wagcs as thcir solc cotnlrcnsation, willdo lhc work and thc stnrture is not <br />intcndcd or ofl'crcd for salc (Sc.c.7O14. Busincss and hofessions Codc: The Contractor's Liccnsc [:w docs not apply to an owncr of <br />thc propcrty who builds or improvcs thcroon. and who docs such work himsclf or hcrsclf or through his or hcr own cmployccs. <br />providcd that such improvcnrents are not intcnded or offcrcd for sah. lf. howcvcr. thc building or irnpmvcnrcnt is sold within onc )rcar <br />of comphtion. thc Owncr Builder will havc thc burdcn of proving that hc or shc did not build or improve the propcrty for thc purposc of <br />sah). <br />-1. <br />as owncr of thc pro;rcfly. am exclusivcly contracting with liccnsed conlractors lo construct thc proict (Sec. 7W. Busincss <br />and Bofessbn Code: The Contraclor's Liccnsc Law does not apply to an owncr of propcrty who builds or improvcs thereon, <br />and who contracts for such projccts with a Contractor(s) licenscd pursuanl to thc Contractor's Liccnsc [,aw). <br />-lamcxcmptundcrScction-,B.&P'C'lbrthisrcason.n^.^. <br />WORI(F'RS' COMPENSATION <br />DECLARATION <br />I hcrcby aflirm undcr pnalty of pcrjury one of the following dcclarations: <br />-l <br />have and will maintain a Certihcatc of Consent to Self-lnsurc for workers' compcnsation. as provided for by Section 3700 of thc <br />L:bor Codc. for the lrcrformancc of thc work for which the pcrmit ls issucd.I <br />lLI havc and will maintain workers' compcnsation insurancc. as rcquircd by Section 3700 of the l-abor Code. for thc performance of <br />thc work which this pcrmit is issued. My workers' compcnsation insurance carrier and policy numbcr are: <br />r b <br />Policy P'-At uvl C 0 l(Utq:.E--:-^-.0) lt}ln- <br />-l <br />certify that in the pcrformance of thc work for which this pcrmit is i.ssued. I shall not employ any person in any manncr <br />so as lo bccome subjcct to thc workcrs'compcnsation laws of California. and agrcc that if I should bccomc subject to the <br />workcrs' compcnsation provisions of Section 3700 of thc [:bor Codc. I shall, forthwith comply with thosc provisions.. <br />I,VARNING: Failurc to scre workers'amlEnsalion covcmSe is unlswful. rnd sh{ll subjst an cmplo)rcr to qiminal lrmltbs and <br />civil fincs up lo onc hundrcd thouwd dolles ($100,000), in addition to thc cost of compcnsation, damges as prcvilcd for thc <br />S6tion 3076 of fic Libor Codc, inlcrcst and rtlorrcy's fes. <br />o,*, oQ/oi / zl n ou*,, Xaviu V anqnlrL <br />IJCENS@-CQNIEAqE)B <br />I hcrcby sllirn undcr pcnalty of tErjury tha, f ", ti*n*a , Chaprs 9 (olrmrcing with sfftion 7u)o) of Divisiotr 3 <br />of thc Busincss and Prcfcsions Codc, ud my liccnsc is in full forc and cff6l <br />Liccnse c,u*.r L Liccnsc Number:t{ rr<*L <br />conrracro.' <0; ILL klnsnuLhen t-rre,-I <br />CONSTRUCTION LFNDING AGENCY <br />I hcrcby affrm undcr ]Emlly of lErjury that thcrc is a constructhn bnding agcncy for thc lrcrforlrrec of tlE work for which this pcrmit is <br />issued (Ss. 3097, Civ. C.). <br />hndcr's Name: <br />lrndcr's Addrcss: <br />APPLICANT DF'CI ARATION <br />I trrcby affrm undcr pcnalty of perjury one of the following dcclarations: <br />Dcmolition Pcrrnits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) <br />_Requircd [.cttcr of Notification <br />-l <br />ccrtify that thc federal rcgulatio$ rcgarding asbcstos rcmvrl uc not applicabb to this prcj$t. <br />Xt[l ccnify that I have rcad this application ad shrc thst thc abovc informtion is comt. I agrc to @mply with all Cityand County <br />odimmcs md Statc hws rchting to building snstructio[ ard hcreby8uthoria rcprcsntstivcs of this City ud County to entq upon thc <br />above mentioned propcrty for puryx)ses. <br />Applicant or Agent <br />i,o, )L-.tlr 4-{V<l n6{ nL t.-l <br />*,", o\lcl (tl <br />Site-Work <br />Underground <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under SIab / Floor <br />Bondinq I Groundina I 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 Rough) <br />[\Ieter Release <br />Rough <br />Service lVleter <br />FINAL <br />Notes, Remarks, Etc. <br />Owner:_ <br />o",. oq/9t/zt