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ELECTRICAL-INSPECTOR RECORD Or..r nO n7 On{tr APPROVALS DATE ID/SIG.COMMENTS I hcrcby afftrm undcr lEnalty of pcrjury lhal I m excmpl ftom the Conracbs' Liccn* law for thc following rcasn (Sc.7031.5 Busioess ard Profcssion Codc): Any City or County vhich rcquircs a pctmit to onslruct. alts, imprcw, dcmlish or rcpairrany structurc, prior to its issuffic, also rcquircs lhc applicont for such pemit to filc a signcd sldcmnt that he or dE is liccnsd punuilt to thc prcvisions of thc Conractor's Liccnsd t{w (Chaptcr 9, Comrcing with Setion 7000 of Division 3 of lhc Business md PrclbssionsCodc)orthothcorshciscxcmptthwfromandthcbasisforthcallcgedcxcmption. AnyviolationofscctionT03l,5byany upplicsnt for a JEmit subjsts thc applicmt to o civil pcn&lty of not mrc than fivc hundrcd dollus ($500). _1. as owner of thc propcrty. or my employecs with wagcs as thcir soh compensation. will do thc work and thc stnrcture Ls rnt intcndcd or offercd for salc (Soc.7044, Busincss and Professions Code: The Contraclor's Licensc [:w does not apPly to an owncr of lhc propcrty who builds or improves thcrmn, and who does such work himself or hcrself or through his or her own cmployccs, providcd that such improvcnrcnts are not intcnded or offcrcd for salc. If, howcvcr. thc building or inqnovenrcnt is rcld within onc )aar of comphtion. the Owner Buildcr will have ttrc burden of proving that he or she did not build or inprove the profrrty for the purpose of sah). _1. us owncr of thc propcrty. am cxclusivcly contracting with liccnscd contractors lo construct thc projcct (Scc. 7M4, Busincss and Protbssion Code: Thc Contractor's Licensc Law does not apply lo an owncr of property who builds or itnproves thercon, and who contracls for such projccts with a Contracto(s) liccnscd pursuant to the Contractor's Liccnse hw). -IamcxemptundcrScction-'B.&P.C.forthisreason'Date: Owner: WORN rRS' COMPF'NSATION DECI ARATION I hercby affum undcr penalty of perjury one of the following declarations: _l havc and will nraintain a Certificatc of Consent to Sclf-lnsurc for workers'compcnsation, as providcd for byScction 3700 of the l,rrbor Code. for thc pcrformance of the work for which thc prmit is issucd. _l havc and thc work for ) will 3700 of the Labor Codc. for thc pcrformancc of arxl gnlicy number are: ur \n'{'d t \o 01 zLPolicy _l ccrtify that in thc Jrcrformancc of the work for which this grcrrnit is issucd. I shall nol cmploy anylrcrson in any manncr so as to bccomc subjcct to thc workcrs' compcnsation laws of California, and agrcc that if I should beconn subytct to thc workcrs' compensation provisions of Section 3700 of thc [:tnr Codc, I shall. forthwith comply with thosc pmvisions.. WARNING: Failurc to srccurc workcrs' compcnsation coveragc is unlawful, and shall subict an employcr lo criminal pcnaltics and compcnsation, damages as provided &rr thccivil fines up to onc hundred thousand dollars ($100.m0). in addition to lhe of Scction 3076 of intcrcst and attorney's l'ccs. ID ('?)q LI DECLARATION . I hcrcby affirm under penalty of pcrjury that I am liccnscd undcr provision of Chapter 9 (comnrencing with Section 70m) of Division 3 of thc Business and Profcssions Code. ard my license is in full forcc and effcct. Liccnsc . C)-O Number:- luqgqqb o Lt W I hcrcby affrm undcr lrcnalty of lEjury thst thcrc is E @nstruction brding agercy for thc pcrfol1we of thc work for whhh this permit k issued (Sec. 3097, Civ. C.). [-ender's Name: lrnder's Address: APPLICANT NF'CLARATION I trcreby affrm undcr pcnalty of pcrjury onc of the following dcclarations: Dcnplition Permits-Asbcstos Notification Fcdcral Rcgulations (Title 40, Part6) -Rcquired lrttcr of Notifrcation _l ccrtify that the fcdcral regulations regarding asbcstos removal are not applicablc to this project. Lh..rtify that I have read this application and state that rhe abovc information is corrccl. I agrcrc to comply with all City and County ordinanccs and State Laws rclalirrg to building and hcrcby authorizc rcprcscntativcs of this City and County to cntcr uJmn thc atxrvc rrrcntioncd propcrly for inspcction Applicant or Agent Pernritee name Site-Work Underqround Pole Bases Liqht Standards Spas, Pool, Fountains Siqns (monument) Life Safetv /Low Voltaqe Fire Alarm / Dampers Communications Cable Buildinq Under Slab / Floor Bondinq I Groundinq I UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouoh Ceilinss (T-Bar Rouqh) N/eter Release Rough Service N/eter FINAL Notes, Remarks, Etc. -I E--:-^.,. _License orr", ' A h4b4