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ELECTRICAL.I NSPECTOR RECORD <br />Rev.08-07-2015 <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hacby aflirm undq pmalty of psjury that I m ercmpl ftom the Contracto$' Licrue law for the following reNn (Sec.7031.5 <br />Busines axl Profsion Code): Any Cily or County which require a po'rnit to corutruct, alts, improvc, donolish or repair my <br />structue. prior to its issumce, also requircs thc applicut for such pqmit to file a signcd statmot that he or she is licmed pmuat <br />to the provisions of the Contractor's Licensed Law (Chaptfr 9, Commencing with S@tion 7000 of Division 3 of the Bsines ed <br />ProfessionsCodc)orthatheorsheisexemptthsefromadthcb6isfortheallegedexmption. AnyviolalionofSationT03l.5bymy <br />applicantforapemitsubjststhc applicanttoacivilpeMltyofnotmorethmfivehundreddollas($500). <br />-1, <br />o orvno of thc property, or my employm with wage o their rcle compmsation, witl do thc work md the struduc is not <br />inrsded or offsed for sale (Se.7044, Businss md ProfesioN Code: Thc Contrac(or's Licmse Law do6 not apply to an oms of <br />the prcpcny who builds or improvs thq@n, ed who do6 such woIt himsclf or hmclf or through his or ho om employce. <br />provided that such imprcvmmts ac not intadq, or offdql for ele. lf, howwq. the tuilding or imprcvmt is pld within one )w <br />ofcornplaioc the Ouns Buildry will have the btrdfl ofprcving that he or she did not build or improve the prcpety for the purposof <br />sle). -/ <br />/ * o** of th. p.p6ly. an exclusively contracting with licffed contracton to construd the prcjqt (Ss. 7044, B6ins/md ProfsionCodc:ThcContractor'sLicenseLawdo6notapplytoilownqofpropetywhobuildsorimprovcsthceon. <br />and who conuacls for such projtrts with a Conlracto(s) lic$cd pumumt to the Contrador's Licme [aw). <br />_l m exelnpt undq B. & P.C. for this r6on. <br />o,t"'rO)- ll' VO <br />DECLARATION <br />I hqcby 8ffim undq poalty of pajury one of the following delaatiorc: <br />_l have md will maintain a Ceflific8te of Coruot to Self-lnsure for work6' compdsation, a povidcd for by Sction 3700 of the <br />Labor Code, for thc pqfomecc of thc work for which lhe pornit is i$ued. <br />_l havc md will mairtain workffi' compcBation iNurilc€, s rcquircd by Setion 3700 of thc Labor Code, for the pqfommce of <br />the work fo( which this pmit is issucd. My work6' composatioo imurilcc tris md policy numbq ae: <br />Cmis: <br />l'olicy Nr Exoirs: <br />_l cfliry that in the psformance of thc rvork for which this pomit is issued. I shall not qnploy any pemn in aoy mmncr <br />e 6 to become subjet lo the work6' compwtion laws of Califomia. and agrs thal if I should becorne subject to the <br />workqs' compcmation provisiom ofSetion .1700 ofthe tabor Codc. I shall. fonhwilh comply with thos prcvisions.. <br />W RNINC: Failure lo scue workers'compmsation covoagc is unlarvful. and shall subject m qnployq to qiminal poaltie md <br />civil fines up lo one hun&ed thousand dollds ($100,000), in addilion lo the cosl ofcompemtion. danages m provited for the <br />S(tion J076 of the Labor Code. inl66t ild attomry's <br />DDCIARATION <br />I hmby aflim undo pcnalty of pqjury that I m licosed udo provision of Chapto 9 (commmcing rvith Sation 7000) of Division 3 <br />of thc Busins ed Prcfsiom Code. md mv licmse is in full force ild effect. <br />License Class:Numbs: <br />CONSTRUCTION LENDING AGENCY <br />I hcreby affim undo penahy of pejury thst th6c is a construction lending agmcy for thc psfommce of thc work for which this pqmil b <br />issucd (Se. 3097. Civ. C.). <br />[Jnd6's Nme: <br />fr <br />tmd6's Addr6: . <br />APPLICANT DECLARATION <br />I herby affm undo poaky ofp€rjury one ofthe following d@ldalions: <br />Demolition P6mits-Asb6tos Notification Fedqal Regulations (Tillc 40. Paa6) <br />-Required <br />Lctts of Notilication <br />_l cqtify that the fedoalregulatiom rcgrdirg abstos removalue not applicable to this prcj{l. <br />-6r*rl have rcad this applicalion ild stale thal the above infomation is corecl. I agre to comply with all City and County <br />'ordinanccs md State taws rclating to building construction, ad hoeby authorizc rcprGmtativc ofthis City and Coun(y to otq upon thc <br />abovc rnmtioncd propeny for pulpos6. <br />-L/Applicsnl or Agetr( <br />Pernrilcc namc . Or..? el <br />Site-Work <br />Underground <br />Pole Bases <br />Liqht 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 />Bonding / Grounding / UFER <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rough <br />Ceilings (T-Bar Rough) <br />Meter Release <br />Rouqh l. <br />Service Meter 3/to/zo .?A 4/) <br />2/FINAL ,X/ eh b'til <br />Notes Remarks Etc <br />o,r",c3'7-lt-VO