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ELECTRICAL-INSPECTOR RECOR D APPROVALS DATE ID/SIG.COMMENTS Site-Work Underoround Pole Bases Lioht Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under Slab / Floor Bondinq lGroundino I UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilings (Hard & Soffit Roush Ceilings (T-Bar Rough) N/eter Release Rouqh Service Meter I I I Ah oFINAL , L1 u \/lv{x6 l'lNotes, Remarks, Etc. I hereby affirnr untler penalty of perjury that I arn exempt fmm the Contractors' License l-aw for the following, reason (Sec.7031.5 Busincss and Profession Codc): Any City or County which requircs a permit to construct, alter, irnprove, demolish or repair any structure, prior to its issuance. also requires the applicant tbr such grcrnrit to file a signed slaternent that lr or she is licensed pursuant to thc provisions ol'thc Contractor's l.iccnsed L-aw (Chaptcr 9. Commencing with Section 70fi) of Division 3 of thc Busincss and Professions Code) or tlut lu or she is exenrpt therefronr and tlre basis for tlre alleged exemption. fuiy violation of Section 7031.5 by any applicant for u pennit subjects thc applicant to a civil penalty of not more than five hundred dollars ($stttt). _1. as owner of thc propcrty. or my crnployccs with wages a.s their solc compensation, willdo ttrc work and thc structure is rrrt intcrxlctl or offered for salc (Scc.70l4. Busincss and Professions Cqle: Thc Contraclor's Licensc Law docs not apply to an owner of the prcgrerty wlro builds or inprows thcrmrl and who does such work himself or herself or thruuglr his or her own entployecs, provided that such irnprovcrrcnts arc rnt intcndcd oroflercd for sah. Il. howevcr, t}c building or inprorrcnrnt is soH within onc ),ear of complctioru the Owrrer Buikler will have the burden of proving tlut hc or she did not builtl or inprove tlre propary for thc purposc of sale). _1. as owner of the property, um exclusively contracting with liccn.scd contractors to conslruct thc projcct (Sec. 7044, Business and hrofession Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contmcts for such projects with a Contractor(s) liccn.scd pursuant to thc Contraclor's Licensc l-aw). -IantexemptunderSectitltt-,B'&P'C.lbrtlrisreason' WORKERS' COMPENSATION DECLARATION I hereby aftirm under grcnalty of pcrjury onc of the following declarations: EL, have and will nraintain a Cerrificate of Coment to Self-Insure for workers' compensation, as provided for by Scction 3700 of thc Labor Code, for the performance of the work for which thc pcrmit is issued. Code, for the Jrcrf<rrttuurce of alc: Policy _l ccrrify that in tlrc ;rrftrrnuncc of thc work for which this pcrmit is issucd, I shall not cmploy any person in any manncr so as to bccomc subject to thc workers'compcnsation laws of California. and agrce that if I should bccomc subject to the workers' conrpensation pruvisiorrs of Section 3700 of the Labor Code, I slrall, forthwith conrply wilh thosc provisions.. WARNING: Failure to secure workers' compensation coverage is unlawful, and shall subject an employer to crirninal penaltics tnd civil fines up to otre hundred thousand dollars ($100.000t. in addition to tlrc cost of contpetusation, danuges as provided for the Sc'ction 3076 of thc [:krr Codc, intcrcst and attorncy's lbes. *,,n*,, Q? (ra(93 ,xpires: ,",., tttza (z-, Licensc crurs, C &() Liccnsc Numbcr:[os13o\ I hercby affirnr under penalty of perjury that I anr licensetl of the Business and l'rofessions Code. aM rny license is in full forcc and effect. Applicant or Agent Itcrmitce name 9 (conrnrncing with Section 7000) of Division 3 I hcrcby al'l'irm undc'r pcnalty of pcrjury that thcre issuetl (Sec. 3097. Civ. C.). a construction lending agency for thc pcrlbrrnancc of thc work lbr which this pcrrnit is [.cnder's Name: Lrnder's Address: APPLICANT DECLARATION I Hry affirm under pcnalty of pcrjury one of thc following declarations: Denrolition Permits-Asbcstos Notification Fcdcral Regulations (Title 40, Part6) _Required l,ettcr of Nuifrcation _I certify that thc fcdcral regulations regarding asbcstos rcmnval are not applicable to this pro!:ct. 3ln ccrtify thar I havc read ttris application urd state tlrar lhe above informarion is corrcct. I agrerc to conply with all City and County 'ordinances and State Laws rclating to building consuuction, and hcrcby authorize representatives of this City and County to enter upon the abovc rrrcntioned propetly for inspection purposes. *,", trtZo (ez, Bev. 08-07-201 5 I)ale: \ztr5 nnre' \L \Z,a lO-> l nrint l.lLa -( [Q ( ^lq t- t/s