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APPROVALS DATE ID/SIG.COMMENTS Site-Work Underground Pole Bases Light Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Buildinq Under Slab / Floor Bonding / Groundins I UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factorv Wired Unit Walls (Conduit)I I t -? Dl'\1n4,.Walls (Roush)1 l@':N Wbz Ceilinss (Hard & Soffit Rouqh \u Ceilinss (T-Bar Rouqh) JVleter Release Rouqh Service N/eter II FINAL I t lo JXtryCI r Notes, Remarks, Etc. OWNER BUILDER DIi,I,CA RATION I hereby affrm untler penalty of prjury that I anr exenrpt from the Contracton' License l-aw for the following, reason (Sec.7031.5 Business and Prol'ession Code): Any City or County which requircs a permit to conslruct, alter. irnprovc. dcmolish or rcpair any structure, prior to its issuance. also reguires the applicurt for such pcrnrit to fih a signed slaternent that lr or she is licensed pursuanl to the provisions of thc Contractor's l.iccnscd law (Chapter 9, Commcncing with Section 7000 of Division 3 of the Business and Professions Code) or that he or she is exen4rt therefrom and tlrc basis for tlre alleged exentption. Any violation of Section 7031.5 by any applicant for a perrnit subjects the applicant to a civilpenalty of not more than five hundred dollars ($5tttt1. _1. as owner olthc property. or my ernployccs with wagcs as their s'ole compensation, will do thc wcnk and the struclurc is not irrterrded or offered for sale (Sec.7H4. Business antl Professions Code: The Contractor's License Law docs not apply to an owncr of the property wlro builds or improves thereorl arxl wlro does such work himself or lrerself or through his or her own enrployees, provided that such impmvcnrcnts arc rnt intendcd orolTercd for salc. Il. hnwever, the building or inproracrrcnt is soH within orc ye:r of conpletion, thc Owncr Buil&r will have the burden of pmving ttrat hc or she did not buill or inrprove tlrc pmpaty for thc purposc of sale). _1. as owner of the property, am exclusively contracting with liccnscd conuactonr to conslruct thc projcct (Sec. 7044. Business arxl hrofesskn Code: The Contractor's Licerrse Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projccts with a Contractor(s) liccnscd pursuant to thc Conuactor's Licensc Law). -IantexemptunderSection-,B.&P.C.forthisreason.Owner: WORKEILS' COM PENSATION DECLARATION I hcreby affirm undcr penalty of pcrjury one o[ thc lbllowing declarations: _I have and will nraintain a Cerlilicate of Consent to Self-lnsure for workers'compensation. as provided for by Scction 3700 of thc L:bor Codc, for the Jrerformance of thc work for which the pennit is issued. _l have arrd will maintain workers' conrpensation insurarrce, as required by Section 3700 of lhe l-abor Code, for lhe lrcrfontutrce of thc work for which this prmit is issucd. My workcrs' comlrcnsation insurance carrier and gnlicy number arc: Policy Number: l:xpires: _l ccrtify that in thc 1,.*rfornnncc of thc work for which this permit is issued, I shall not cnrploy any pcrson in any manncr so astobccorncsubjccttothcworkcrs'conrporsationlawso[California,andagrcethatiflshouldbecomcsubjecttothe workers' conr;rnsation provisions of Section 3700 of the labor C'otle, I stull, forthwith conrply with those provisions.. WARNING: Failure to secure workers' compensation coverage is unlawful, and shal! subject an cmployer to crirninal penaltics and civil fines up to one hundred thousand dollars ($l00.Un). in addition to the cost of compctsation. danrages as provided for the Section 3076 of the [:tnr Codc. intcrcst and attorncy's l'ccs. LICENSED CONTRACTOR DECLAITATION I hcrcby affirnr under pcnalty of perjury that I anr licensal under provision of Chapter 9 (conutrcncing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full forcc und effect. License Class: License Number: fl.,r -. CONSTRUCTION LENDING AGENCY I hcreby allirm under Jrcnalty of pcrjury that thcrc is a construction lcnding agency for the perlbnnance of the work ltrr which this pcrmit is issued (Sec. 3097. Civ. C.). lrnder's Nanrc: lrnder's Address: APPI,ICANT DECI,ARATION I hrcby affrnr under pnalty of pcrjury one of thc following rlcclarations: Dcnrclition Pernrits-Asbcstos Notification Fcdcral Rcgulations (Tille 40, Part6) Requircd lrttcr of Ntxif,rcation _l certiti that thc fcdcral rcgulations regarding asbestos rcmcrval iue not applicablc to tHs pro]xt. _l certify that I luvc rcad this application urd stutc that lhc above infornution Ls corrcct. I agrcc to comply with all City and County ordinances and State Laws relating to building constructioru and hcrcby autlnrizc rcprcscntatives of this City and County to enter upon thc abovc mentioned propcrty for inspection purposcs. Applicant or Agent Date:- I'crnritec nanrc ( nrinl l: ELECTRICAL-INSPECTOR RECOR D a Rev.08-07-201 Conlractor: