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APPROVALS DATE ID/SIG COMMENTS <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Transformers <br />Torquing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soffit Rough <br />Ceilings (T-Bar Rough) <br />Meter Release <br />Rough ^Service lt/eter Q/a,i/t.t , <br />(lrv(sb-)nTn?7eq7rvFINAL( <br />Notes, Remarks, Etc I <br />Ou,ner-Builder Declaralion <br />I hereby affirm under penalty of perjury thBl I anl exempl form the Conlractors' License Law for the lollowinS reason (sec.70J 1.5 Busincss <br />and Profcssion Code): Aoy City or County *'hich rcquires a pcnnit to coNtrud. allcr. improvc. dcmolish or rcpair any structure, prior lo ils <br />issuancc. also rcquires lhe applicant for such pcmil lo filc a signed statcmenl that hc or she is licenscd puBuant lo thc provisions ofthc <br />Conlractor's l,icensed L.w (Chapte. I, Conrmencing wilh Section 7000 ofDivision 3 ofthe Business and Professions Codc) or lhst hc or <br />shc is crcmpl thcrcfiom and thc bsis for thc allcgcd crcrnption .Any violation of Scction 7031.5 by any applicanl for a pmil subjccts lhc <br />applicant to a civil pcnalty ofnol morc than fivc hundred dollam ($500). <br />_ l.as ownerofthcpropeily.ornrycmployccswilhwag6astheirsolccompcnsation.willdothcrvorkandlhcstruclucisnolinlcnded <br />or offered for sale ( Sec ?044. Business and Professrons Code The Contractor's Lrcense l,aw does not apply to an owner ofthe propcny <br />rvho builds or improv6 thcrcon, and who does such work himsclfor hersclfor through his or her own cmployces. proridcd that such <br />improvcmcnls arc nol intendcd or offcrcd for salc. If. horvcvcr, the building or improvemcnt is sold within onc yesr ofcomplction. thc <br />O\rncr-Buildcr will hal'e lhc burdcn of prol ing thal hc or shc not build or improvc for lhc purposc of sale). <br />_1. as owncr of th. propcny. am cxclusivcly contraoing with licc$.d conlmcloN to conslrud thc projccl ( Sec. 7044. Busines and <br />Profcssion Codc: 'l hc Conlr6ctor's [,icensa llw do.s not apply lo rn owner of propeny who builds or inlprovcs thcreon , and who <br />contractr for such projects with 6 Contraclor(s) licensed pursu6nt to the ('ontrador's License l,6w ) <br />I anr excrnpt under Scclion .8. & P.C. for this rcason. <br />Date: ()rvncrl <br />WORKERS COMPENSATION DECLARATION <br />I hereby aflirm under penally ofpcrjury onc ofthe following dcclaralions: <br />I have and will maintain a Ccrtificale ofConsent to Self-lnsure lor workers compensalion. as provided for bv Sctron 3700 ofthe <br />I-abor ('ode. for lhe perfonnance of lhe lvork for which th. pennit is issued. <br />I have and will maintain workers' compenslion insurance, as required hy Section 3700 ofthe libor Code, for the perfornrance ofthe <br />work for which this permil is issued My workers' conpensatron ansurance 6rrier and policy number are <br />Carrier: <br />Policy Numbcr:____Expircs: <br />(This scction nccd not bc comptaid iath" p.-ut ir f"r O"" h,r"d.d d"ll* l$l 0O) or less) <br />I ccnify thel in the pcrfornrance ofthe work for <br />became subject h the workers ' compenslion laws <br />rvhich this pemit is issucd. I shall not employ any pc6on in any manner so N to <br />if I should become subj(t to the worlers <br />compensattrn provisions oi scclhn 1700 ,abor lvilh those provisi{rns. <br />I )xle' <br />IVARNlN(; Failure lo secure workers unlasful. and shall subiecl an empk)vcr to frirlinal penaltia and civil <br />fincs up lo onc hundred thousand dollars ($l <br />thc Iatxrr ( ode. inlercst anrl allorner"s fes <br />addition to-lhe .ost ofcompensothn, d^ma8es as provided for lhc Seclion .1076 of <br />LICENSED CON'TRAC'TORS DECLARA'TION <br />I hereby affirm under pcnally of perjury that I am liccosed undcr provision of('haplcr I (comrnencing wilh Section 7fi)0) of Di!ision .l of <br />lhc Business and Professions Code. and mv liccnse is in full force and effect. <br />[,icense Class: <br />Dslei <br />I herchy affirm under penahy ofperjury thal <br />issued (Scc. :t0S7. Cn. C.). <br />Lender's Nanre <br />isa lcnding agcncy for the perlormance ofthe lvork for which this permil is <br />l-ender's Address <br />APPLICAN'T'S DECLARATION <br />Denrolition Permils-Asbeslos Nolificalion l.-edcral Regulations ('l ille 40. I'an 6) <br />Rcquir.d I-clter of Nolifi calion <br />I cerlify Ihal lhc rcgulalions rcgarding asbeslos ren()val are rrct applicahle lo this projecl. <br />rllal rcad ion and stale thal the ahove informalion is cotrecl. I o8ree to conrply rvith all ('ity and County <br />co6lruclion, and hcrcby authorizc rcprGcntali\..s ofthis City and County to cntcr upon lhc <br />ahove y for <br />a)uLLApplicant <br />Pqmitte <br />sig.: <br />') <br />(trinl):W Dalc:_ <br />ELECTRICAL.INSPECTOR RECORD <br />.a' -. <br />M:\WP5'1\Permit-lnspectionForms\Eleclrical-lnspeclionRecord.doc 03.31.06