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DATE ID/SIG.COMMENTSAPPROVALS <br />Site-Work <br />Underqround <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 />Building <br />Under Slab / Floor <br />Bondinq / 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 (Rouoh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinos (T-Bar Rough) <br />lrleter Release <br />AI fznr*Rouqh 0/t ,/,4 ?-\r t <br />Service [/eter <br />IFINAL '-6/--/ t sb-t8 / r.'/ S 44// <br />Notes, Remarks, Etc. <br />-) <br />J,tl':,'"r[i,ljlril',':il:at];xl.:]"irirl; rx,,lr rhIl,"xi,:;,il':il <br />strlrclurc. prior t() its i\\uancc. rlso rcquirc\ lhc rpplicanl for such Jrcrnril k) lilc a qigncd stalcnlctrl lhrt lr or shc is liccrrrcJ pursuilJ <br />lo thc pmvisions ol-thc Conlrrclor'! Liccnsc(l I-rw (Chaplcr 9. (i)ntrrcncing wilh Sccliol 7fiX) ol l)ivision J of thc Bu\incss atd <br />rpplicrnlli)rapcrmilsuhjcclsthc upplicxntlorcivilpcnnltyo{noltrx)rclhrnlivchundrcd(lollars(S5{n). <br />I. as owncr oflhc propcily. (tr my cnlpk)yces wilh wrgcs ds lhcir solc coolpcnsilli()n. will d() lhc work xnd lhc slruclurc i\ n(il <br />lhc pnrprty *'ho huilds or inrprrvcs Ihcre\)n. rnd who docs \uch work hirn\clfor hcr\ell or lhrrugh his or hcr own cnrphyccs. <br />ol conlplclinr. tlr Owncr Buikler s ill huvc the burlcl ol provinS lhat hc or shc rlid n(i huild or irnprovc lhc pr)Fny lbr lhc purx)r ol <br />\rlc I <br />_1. as owncr of lhc p()pcny. am cxclusivcly conlracting wilh laccnscd conlruck)rs lo conslrucl lhe projccl (Scc. 7()1.1. Bu\inc\s <br />rnd P()lirs\irl Codc: Thc Contrilclor's LiccDsc Law docs ilol apply lo an owncr ofpropcrly who builds or improvcs thcrcon, <br />and who conlrrcls li)r such prejccls wilh { C-'orilraclor(s) liccnscd pursurnl lo lhe Conlraclor's Liccilsc Law). <br />-ltnrcxctr|DlunrlcrScctitrn-.I].&P'C.l()rlhisrcason.l)rtc ()wner:_ _ _ <br />wtlnxnns' coutrrnslnox <br />-DECLARATION <br />I hcrcby affirnr undcr pcnahy of Jrcrjury onc of thc lbllowinS dcclffat i(,nsl <br />_l havc ilnd will maintain r Ccdificilte of Conscnt k) Sclf-lnsurc li)r workers' conlpcnsntion. rs providcd for by Scclion .3T{X) of lhc <br />hhor Codc, f<rr thc pcrlhrmrnce of thc work li)r Nhich thc Frnlil is issucd. <br />_lhavcandwillnlainluinworkcrs'compcrsillioninsurance.trs rcquircdhySection3T0Oofthel-rborCode.li)rthcpcdornanccof <br />thc work for which this pcrnit is issucd. My workcrs comlrcnsation insurancc caris und F)licy nunlbcr trc: <br /><(9\| '\-4> (o- <br />(' <br />_l ccnily rhrt in thc pcrforrmncc ol lhc work for which lhis pcrnril is irsucd. I shall nol cmploy any person in any manncr <br />s(, as to hcconr subjecl lo lhc w(,rkcrs' conrpcnsal ion hws of CulilbrDia. and ugrcc thst if I should bccoilrc suhFcl to lhc <br />workcrs'compcnsationfrovisionsofScction3Til)ofthcl-aborCotlc.lshall.forthwilhconlplywilhthoscprovisions.. <br />IVARNING: f:ailurc h *curc workcrs'compcnsrlion covcmgc is unlawlul. and shall subjcct an cmploycr to ftiminal frcnallies and <br />ci!il linc\ up lo orc hundrcd thousand tlolhrs (Sl(x).(xx)). in nd(lilion lo thc co\l ofconr|cnsrtion.tbr lhc <br />'""utrARn" [ffiod21tg'id <br />nkmcv s <br />l)aie: -l - -. - Applicant: <br />l'ccs. <br />I hcrchy allirm undcr pcnahy of pcrjury lhut I am licensd undcr provisi(rl ofChaptcr g (comrmnci[g wilh Scclion 70{D) of Division 3 <br />of thc Busincss and Professions Codc. dnd ilry liccnsc is in full tbrcc mtl cflcct. <br />l-iccnsc Nu rnhcr:x <br />CONS'I'RUCTION LENI)INC AGENCY <br />I hcrchy allirrl undcr pilalty of rcrjury thal thcrc is a constructiru lcndinS agcncy for the pcrlbrnrilncc of lhc work for which lhis Frcrmil is <br />issucd (Scc. 3097. Civ. C.). <br />Lcndcr's Nanrc: <br />Lcndcr's Addressl <br />APPLICANT DECLARATION <br />I fmhy allinn undcr pcnalty of pcrjury onc of thc krllowing decluationsr <br />Dcmoliliotr Pcrmits-Ashcsms Notification Fcdcral Regulations (Tillc 40. Pan6) <br />-Rcquired <br />Letlcr of Nolilication <br />_l ccnily lhal lhc fcdcral rcgulillions rcgtrding n$hcslos rcrnoval ilrc n(il applicahlc lo lhis projccl. <br />(pr.=mry rrrn I hrvc rcild rhi\ anplicar <br />ordrnanccs rnd Stalc Iiws rcliilinP lo hui <br />ion and stalc thrt thc atxrvc inlbrnutioil is coficct. I with all City and Counly <br />and Counly to cnlcr upon lhcikl ing <br />abovc nrcntioncd pRlpcny l'or inspcclion <br />Applicanl or Agrnl x <br />I'cmritrr ntrnrr (print): {+vb1 <br />, <br />I )irlr <br />ELECTRICAL.INSPECTOR RECORD <br />0.,,"r",,,*.' fF -lL^gc-B 6 ?ti ?6? ,"r,,"" <br />a (l tt*t <br />l)illc __pu/\