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ELECTRIGAL.I NSPEGTOR RECORD .l <br />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 lDampers <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 <br />Service Meter <br />FINAL <br />Notes, Remarks, Etc. <br />I hcrcby afiim un&r pcnalty of pdjury thst I m cxmpt fm thc Cdtracto6' Limc Law for thc following rrco (s.7031.5 BEin6 <br />ud Prcfsim Codc): Any City q Cuty which rcquirc a pcrmit to cmrud, alta, imprcvc, dmolish or rcpair sy structurg priq to its <br />ismcc, also rcquirc thc applicmt fq such pemit to filc a signcd statmat that hc q shc ig licmscd punuut to thc provisiqs of thc <br />Contnctor's Liqrd Lrw (Chapar 9, Cmmcing with Sctim 7000 of Divisim 3 of thc Buins ud Prcfeim Codc) or thu hc c <br />shc is aan4n thcfm md thc b8is fa thc rllcSrd qmptim .Any violatio of Setiq 7031.5 by ay 8ppli@t fc a pcmir subjcts rhc <br />applimt !o 8 civil Faslty of not tlm rhe Iivc hu&cd dollm (3500). <br />-L <br />I om6 of thq propcrty, c my cmployq with wa86 I thcir rclc mpcnsaim, will do thc wqt ud lhc sEuslw is oot intcndcd <br />u otfcttd fc salc ( Sc.7044, Buind ud Prcf*ions Codq Thc Cmracor's Limc Law dm not apply to e fln6 of thc Fopcrty <br />who builds u irnprove thoon, ed who dG rwh wq* himclf q hmclf c thugh his c ha own mployc, !rcyidcd that ruch <br />imprcmts rc not idcndcd tr off@d for salc. If, howcv6, thc building c impovmnt is sold within onc yo of omplaim, thc <br />Oma-Builda will havc thc burdo of prcvint that hc tr shc not build u imprcve for thc purpoec of salc). <br />_I, a omq of thc prcpcrty, m qcluiycly mtrrcting with limcd mtrrctG to mtruct thc Foj6t ( S@. 70,14, Bqinc md <br />Prcfsim Codq Thc Cutsetc's Li@sc lrw de not aIryrly to m oma of propaty who builds a imFov6 rhffi , ed who <br />mrra fff ruch prcjds with a Contracrd(s) lifficd punwt to thc Cotncls's Licm L8w.). <br />_I arn exempt under Section <br />Date: <br />& P.C. for this reason. <br />WORKERS COMPENSATION DECIl\NAfl ON <br />I hrcby afrim m&r ponlty of po'jury oc of thc follwing doclanriru: <br />_I havc ud will maintain a Ccnilicrrc of Cms6t to Sclf-lBE ftr wo*6' Gmpcosarion, s providcd fq by Sctim 3700 of thc <br />for the performance of the work for which the p,ermit is issued. <br />and will maintain workers' compcnsation insurance, as required by Section 3700 of the Labor Code, for thc performance of the <br />for which this is issued. My rnsurance carTrer number are: <br />Policy or <br />(This section not bc complcted if the One or less) <br />_I certi$ that in the performance of the work for which this pcrmit is issued I shall not employ any pemon in any manner so alr to <br />became subject to the workers ' compensation laws of California, and agrcc that if I should bccome subject to the workcrs' <br />compensation provisions of Scction 3700 of the Labor Codc, I forthwith thosc provisions.. <br />/L <br />WARNING: Failure to secure workers'compensation coverage is and shdl subject an cmployer to crimind penalties and civil <br />6n6 up to onc huo&cd thruad dollm (t I 00,m0),i, additid to lhc 6t of @mpcnsatio, &magc r prcyidcd fq thc Setio 3076 of <br />thc Labor Codc, irt66t md attmcr's fG. <br />LICENSED CONTRACTORS DECLANATION <br />I hmby aflim uda pmalty of pcrjury thst I m licmcd u&r prcvisim of Chapr 9 (mmdcing with S6{ion 7000) of Divisio 3 of <br />thc Buine md Prcfciiotr Codr, ud my licmc ir in full fre ud cffet. <br />License License <br />Date: <br />CONSTRUCTION LENDING AGENCY <br />I hereby affirm under penalty of perjury that thcre is a construction lending agency for thc performance <br />issued (Sec. 3097, Civ. C.). <br />of the work for which this permit is <br />Lcnder's Name: <br />Lcnder's Address: <br />Dcmlitim Pmits-Asbetc Notif icaim Fcdaal *rffi_ Rcquircd Lrna of Notificatio <br />-l.crt(&that <br />thc fcdsal rrgulatifis rcgarding sbetoc moval rc not applicablc ro this proj@t. <br />ffir, *nrn t rcad this applicatio ud stdc thal thc abovc infmstio is ffil I lgr io cmpty eith all city md coutyqdirec md Statc Laws rclaring to building maucrim, md hmby uthcirc rcprcalstivc of this City ild Cosnty to ar6 upoo thc <br />above mentioned property <br />Applicant or agent <br />Perminee narne (print): <br />o <br />t <br />,