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ELECTRICAL.I NSPECTOR RECORD <br />Rev.08-07-2015 <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hoeby affrm under poalty of psjury lhal I m exempt from the ContracloE' Licose [aw for the following rwn (.\ix 7331-5 <br />Busincs ud Profsion Code): Any City or Couily which rcquire a pornit to co$trucl. altc. irnprovq dmolish or rcpair my <br />structue, prior to its isuuce, also requirB the applicilt for such p€mit to file a signed statonent that hc or she is licmed pmuat <br />to thc provisions of the Contractor's Licenscd Law (Chapttr 9. Comencing wilh Sstion 7000 of Division 3 of the Business md <br />ProfcssionsCode)orthatheorshcisexemptthgefromedtheb6isfortheallegedexemption. AnyviolationofsectionT03l.5byany <br />applicantforaprmitsubjectsthe applicanltoacivilpenaltyofnotmorelhmlivehundreddollas($500). <br />I. o omq of the propeny, or my employc wilh wags r their rcle compenstion, will do fie work md (h€ sructue b mt <br />intodcd or offqed for sle (Sa.7M4, Busine ad Profsions Code: The Contrador's Liccre kw do6 not apply lo m oMq of <br />theprcp.rty whobuildsorimproveth@n.ildwhodoBsuchwrkhimselforhrselfortlroughhisorhrownemployce. <br />provided that such improvmots ilc not intmdcd or offard for sale. If. howdd, thc building or imprcvment is mld within one )q <br />ofcomplaion. the O\vnq Builda will have the budm ofprovitrg that he or shc did not build or imFove the prcpqty for the purpos of <br />ele). <br />_1, 6 owns of thc prop€rty. m exclsively contraaing with licmed contractoB to construct the prcjwt (SE. 7044, Bsins <br />ed Proft$ionCodc:TheContractor'sLicenseLawdo6notapplytomown6ofprop€rtywhobuildsorimprovesthscon, <br />and who contracts for such projccts with a Contrado(s) licssed pumuant to the Contractor's Licose Law). <br />I m exmpt undq Sclion-, B. & P.C. for this r6on. <br />l)8te: <br />WORKERS'COMPENSATION <br />DECLARATION <br />I lroeby allirrn undcr penalty ofpojury one ofthe following declrations: <br />_l have md will mainlain a Certificate of CoNmt lo Self-lNure for workm' compmation. c prcvided for by S€tion 3700 of thc <br />Labor Codc. for the pefommce of the wort for which the pcrnit b i$ued. <br />_l have and will rnainlain workss compensation insurance, 6 by Section 3700 ofthe Labor Code, for the pofonnoce of <br />the work for which this pmnit is issucd. My workos cmie md policy nurnbo ae: <br />Policy <br />_l cdify that in the performance of the work for which this pomit is issued, I shall not employ any peruon in any mmner <br />so d lo become subjst to the workss'cornpensation laws ofcalifomia. md agree that ifl should bocome subject to thc <br />workqs' compmation provisiom of Selion 3700 of the Labor Code. I shall. fo(hwith comply wilh tho* provisioro.. <br />WARNING: Failurc to sue rvorkm'compmation covcagc is unlawful. md shall subjct m mploya to oiminal pqnhies'md <br />civil lincs up to one hundred thousad dollus ($100.000), in to thc cost of compensation. danages ro provided fC. thc <br />Sccti(m 1076 lhe Code. intcrest and <br />I hoeby affrm unda poalty of perjury that I m licosed undo provision of Chaptc 9 (commmciog with Sdion 7000) of Division 3 <br />of the Busins md Profcssiom Code, md my licme is in full force md cffect. <br />C-o L9 2014Liceroe <br />?P1o <br />CONSTRUCTION LENDING ACENCY <br />I hacby affm unda pmalty of perjury that th6e is a coNtruction l@ding agmcy for the psfonnmce of the work for which this psmit is <br />issued (56. 3097, Civ. C.). <br />knds's Name: <br />Lendcr's Address: <br />APPLICANT DECLARATION <br />t ho@ atrm undq penalty ofpcrjury one ofthe following daluations: <br />Dcmolition Pmits-Asb6tos Notificalion Fcdaal Regulations (Tille 40. Pm6) <br />__Rcquired Ldtq of Notification <br />lhis prcjst. <br />I agre to comply with all City and County <br />ofthis City md County lo entq upon the <br />above mentioned property for <br />Applicaill or,{g(nl <br />Pcrnrilcc nsme <br />zo <br />Site-Work <br />Underqround <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 />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 (Rough) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilings (T-Bar Rough) <br />Meter Release <br />Rough <br />Service Meter /_ <br />FINAL qZ/za-,, r4?4 '/ <br />Notes, Remarks, Etc.I <br />I)ate: