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ELECTRICAL-INSPECTOR RECORD <br />()r.r, nA n7 Onltr <br />APPROVALS DATE ID/SIG.COMMENTS oWNERBUILDERDELCARATION .I hcrchy affirm undcr Fnalty of pcrjury thot I m crcmpt fmm thc Contracto6' Licenrc kw for thc followitrg Msn {Ss.7031.5 <br />Business ard Profcssion Codc): Any City or County which rcquircs a JErmit lo @nsIrucl. alls, improvc. dcmlish or rcpair st <br />structurc. prbr to its issuffie, ds rcquircs the appticsnt for such [rcmit to filc a signed statcmil thal h. or slrc is liccn$d pml6ni <br />to lhc pmvisions of thc Conractor's Liccnred t:w (Chapier 9, ComncinS wilh Scction 7000 of Division 3 of thc Busiress und <br />PrcfcssionsCode)orlhuthcorshciscxcmptthcrefmmandthcb&sisforthcalhgcdcxcmption. AnyviolationofScctionT03l.5byany <br />applicant for s Jrcrmit subjccts thc applicant to a civil pcmlty of not mrc than fivc hundrcd dollus ($5fl)). <br />-1, <br />as oercr of thc prcFny, or my cmplo)rys uith wagcs s thcir sle compcnsstion. willdo tlrc work and tlrc stnE{E is mt o <br />intcndcd or offered for sle (5(.7044, Busincss and hofcssions Codc: Thc Contractor's Licetrs law does not apply to an owrcr of <br />the pDIEny who builds or inpmws th€ffin. .nd who d@s sch mtk himsclf or hcrsclf or thrcugh his or hcr own employes. <br />providcd that such imprcvcmnts rc not iilcrdcd or offclcd for $b. If. howw, thc buiHing or improremnt is $H sithin onc )cu <br />of otr{rhtion, thc Owrcr Buikkr will harc the hurdcn of prcving that hc or shc dil mt build or improrc trc pmFrry for thc prqns of <br />sb). <br />_1, as owncr of the propcrty, am exclusivcly contracting with liccnscd contraclors to construct thc projcct (Scc. 7U4. Busittcss <br />and Prrofcssion Codc: Thc Contractor's Liccnse Law does not apply lo an owncr of proFrcrty who builds or itnprovcs lhcrcon. <br />and who contracts for such projccls with a Contraclor(s) licenscd pursuanl to thc Contractor's Liccnsc [:w). <br />-lamexcmptunderScction-,B.&P.C.forthisrcason. <br />f\oto. <br />WOIIKERS' COM PENSATION <br />DECI dRATION <br />I hereby affrrn undcr Fnalty of pcrjury onc of thc following dcclarations: <br />_l havc and will maintain a Ccrtificatc of Conscnt to Self-lnsure for workers' compensation, as provided for by Section 3700 of the <br />I-abor Codc. for the pcrformance of thc work for which the pcrmit is issued. <br />-l <br />havc and will maintain workers' compcnsalion insurancc. as rcquircd by Scction <br />the work for which this pcrnrit is issucd. My workcrs' compensation insurance ciuricr <br />37fi) ot'thc Labor Codc. lirr thc pcrl<lrnuncc of <br />+Tfr't3ql*' <br />/c lf- LPolicy <br />_l ccrtify that in thc pcrforrnancc of thc work for which this Jrcrmit is issued. I shall not cnrploy any pcrson in any manncr <br />so as to bcconr subject to the workcrs' compensation laws of California, and agrcc lhat if I should becomc subjcct to the <br />workcrs' cornpcnsation provisions of Section 3700 of the l-:bor Codc. I shall. forthwith comply with those provisions.. <br />WARNING: Failurc to sccure workcrs' comlrcnsation covcr.lgc is unlawful. and shall subjcct an employcr to criminal pcnaltbs and <br />civil lincs up to onc hundred thousand dollars ($100.000). in addition to thc cost of comlrcnsation. darnagcs as providcd for thc <br />Section 3076 thc Codc. intcrcsl and attorncy's <br />I hcrcby afflrrn undcr pcnalty of pcrjury lhat I ant liccnscd undcr 9 (comnrcncing with Section 7000) of Division 3 <br />of thc Business and Profcssions Codc, and my liccnsc is in full forcc and cffcct.)1,ltf(Liccnsc Llo 2A vL .L Numbcr: <br />\ rl-- <br />W <br />I hcrcby aflirm under Jrcnalty of pcrjury that ttm is a snstruction bnding agency for lhc performrce of thc work for whkh this pcmit is <br />issucd (Sc. 3097, Civ. C.). <br />kndcr's Nam: <br />I-rndcr's Addrcss: <br />APPLICANT NECLARATION <br />I lrreby afl'irnr under pcnalty of prjury onc of thc following dcclarations: <br />Dcmolition Pcrmits-Asbcstos Nolification Federal Rcgulations (Title 40. Part6) <br />_Rcquircd lrttcr of Notification <br />_l ccrtify that thc fcdcralregulations regarding asbcstos rcmovalarc nol applicable to this projcct. <br />_l ccrtily that I havc rcad this statc that thc abovc intbrmation is corrcct. I agrec to comply with all City and County <br />ordinanccs and Statc Laws constructi<ln. and hcrcby authorizc rcprcsentativcs oI this City and County to cntcr upon the <br />abovc rrrcntioncd propcrty trlr <br />Applicant or Agenl <br />I)ernrilee <br />purF)scs. <br />\r-'h -/rr- <br />+ffi <br />Site-Work <br />Underground <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bondinq I Groundinq I UFER <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factorv Wired Unit <br />Walls (Conduit) <br />Walls (Roush) <br />Ceilings (Hard & Soffit Rouqh <br />Ceilinqs [-Bar Rouqh) <br />N/eter Release <br />Rouqh <br />Service N/eter I <br />FINAL tJz^ le,tr[q^ <br />Notes, Remarks, Etc.rf v <br />_ Owner: <br />Exnircs: <br />(r.--(nrr^.o^--)