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ELECTRICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS Site-Work Underqround Pole Bases Lioht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under Slab / Floor l t)Bondinq / Groundino I UFER Lt 'rt+a Transformers I Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouoh Ceilinqs [-Bar Rouqh)I I Meter Release Ir /t,w )kw31o, I Rough I Service N/eter ll (lu -l,O >wgq FINAL 1r/ Notes, Remarks, Etc.II OWNER BUILDER DI,LCARATION I hereby affirnr under penalty of prjury that I anr exenpt frorn thc Contractors'Licensc [:w for the following rcason (Scc.7031.5 Busine-ss and Prolbssion Codc): Any City or County which requires a pcrmil to construct, alter. improve, dcmolish or rcpair any structure, prior to its issuance. also requires the applicant for such Jrernrit to filc a signcd slaternenl that he or shc is liccnscd pursuant to thc provisions of the Contractor's l.iccnscd L-aw (Chaptcr 9. Commcncing with Section 7000 of Division 3 of the Business and Professions Code) or tlut lre or slu is exempt therefrom arxl tlre basis for tlrc alleged exenption. Any violation of Section 7031.5 by any applicant for a permit subjects thc applicant to a civil penalty of not more than five hundred dollars ($5Ott1. _1. as owncr ol'thc prol*-rty.or my ernployecs with wages as thcir sole comgrcnsation, willdo thc work and the stnrcture is not interxlal or ofTercd for sah (Sec.7tX+. Business and Professions Cotle: The Contraclor's Licensc Law docs not apply to an owner of the propcrty wlxr builds or inpnrves ttrreon, and wlro &rs such work himself or lrerself or through his or her own employees, provided that such improvcnrcnts arc rnt intended or offcrcd for sah. Il, hcrwever, thc building or inprovcrnent is sold wilhin onc ycar of comphtioru thc Owncr Buikler will have thc burdcn o[proving that hc or she did not builJ or improve ttrc property for thc purposc of sah). _1. as owner of the property, amexclusively contracting with liccnscd conlractors lo construcl thc project (Sec. 7044, Business arxJ Prutbssion Code: The Contractor's License Law dtxs not apply to an owner of property who builds or improves lhereon. and who contracts for such projc'cts with a Contractor(s) liccnscd pursuant lo lhc Conuador's Liccnsc Law). _l anr exempt under B. & P.C. lbr this reason. I l^. ^. WO RKE,RS' CO[}T PIiNSATION DECLARATION I hcreby aflirnr undcr pcnalt.v of perjury onc of the tblkrwing dcclarations: _l have ard will nrainlafur a Certilicate of Consent to Self-lnsure for workers'conryrensation, as provided for by Scction 3700 of the L:bor Code, for the pcrlorrwrce of thc work lor which thc pcrmit ls issucd. _l have and will maintain workers' conr[rcnsation insurance, as required by Section 3700 of thc l-abor Code, for the perfornunce of thc work for which this permit is issued. My workcrs' cornpcnsation insurance carricr and policy number are: Policy Numher: Expires: _l ccrtify that in tlrc Jrcrftrrnuncc of thc work for which this Jrcrmit is issued, I shall not cnrploy any pcrson in any manncr so as to bccomc subjcct to the workcrs' compcnsation laws of California. and agrcc that if I slnuld bccorne subjcct to the workers' conrpensation provisiors of Section 3700 of the labor C'ode, I shall, forthwith conply with thosc provisions.. WARNING: Failure to sccure workers' compensation coveraSc is unlawful, and shall subject an cmployer to oiminal pcnaltics and civil fines up to one hulxlred thousand dollars ($100.0001. in arldition lo the cosl of compensalion, danuges as provided for lhe Section 3076 of the latnr Codc, intcrcst and attorncy's [ccs. LICENSED CONTRACTOR DT]CLARATTON I hercby affirm under penalty of pcrjury that I anr licensctl under provision of Chaptcr 9 (cornnpncing with Scction 7000) of Division 3 of thc Business and Professions Code. and rny licensc is in full forcc and cffect. License Date: Numbcr: CONSTRUCTION LENDING AGENCY I hcreby allirm undcr pcnalty of pcrjury that thcrc is a construction lcnding agency lor the pcrlbrmance of thc work lbr which this permit is issued (Sec. 3097. Civ. C.). lrnder's Name: I-ender's Address: APPI,ICANT DECI,ARATION I herchy affirnr undcr pcnalty of pcrjury one of thc following dcclarations: Dcnxrlition Pcrnrits-Asbestos Notification Fcderal Rcgulations (Title 40, Part6) -Rcquircd l,cttcr of Notifrcation _l ccrtify that the l'cdcral regulations rcgarding asbcstos rcmoval arc not applicablc to this projcct. I certify tlrat I havc read this application and state tlrat thc above information is corrcct. I agrce to conrply with all City and County ordinances and Statc taws rclating to building construction, and hereby authorize represcntatives of this City and County to enter upon the above rrrcntioned properly for inspcction purposes. Applicant or Agent Signature: Date:- Permitce name (print): ev. 08-07-2015 hltq* I bA-*n