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ELECTRICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS Site-Work Underground Pole Bases Liqht Standards Spas. Poo!, Fountains Siqns (monument) Life Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Buildinq Under SIab / Floor Bondinq I Groundins I UFER ILIIL ,?p \Lil& Transformers Torqueino Sub-Panels Air Conditioners Roof Top Equipment Factorv Wired Unit Walls (Conduit) Walls (Rouoh) Ceilinss (Hard & Soffit Roush Ceilinss (T-Bar Rouqh) N/eter Release x; Rouqh Ir _,, Service N/eter [?t [.'L0 >(Wb1 T'M,WXF!NAL Notes, Remarks, Etc.I D OWNER BUILDIiR DIiI,CA RATION I hereby affirnr under penalty of prjury that I anr exenrpl from the Cbntractors'Licensc Law for the following reason (Sec.7031.5 Business and Profcssion Code): Any City or County which requircs a pcrmit to construct, alter, irnprove, dcmolish or rcpair any structurc, prior to its issuance. also requires the applicart for such permit to filc a signed statemenl that lr or she is licensed pursuanl to thc provisions of thc Contractor's Licenscd l.aw (Chaptcr 9, Comrnencing with Section 7000 ol' Division 3 of thc Business and hofessions Cotle) or that lre or she i^s exempt therefrom and tlre basi.s for tlre alleged exemption. Any violation of Section 7031.5 by any appliclnt for a pcnnit subjects the applicant to o civilpenalty of not more than five hundred dollars ($5{tO;. _1. as owncr ol'the propcrty. or rny cmployecs with wages as their sole compcnsation, will do thc work and thc structure is not intenlcd or offered for salc (Sec.7H4. Business and Professions Code: The Contractor's License Law rJoes not apply lo an owner of the propcrty wlxr builds or improves tlrereorL and wlro dtxs such work himself or lrerself or ttrough his or her own employees, providcd that such improverncnts arc not intcnded or olTercd for sale. Il. however, thc building or improverncnt is sold within onc ycar of completioq tlr Owner Builder will have the burden of proving that hc or she did rxlt buikl or improvc 0rc property for thc purpose of sah). -1. as owner of the properly, am exclusively contracting with licenscd conlraclors to conslruct thc project (Sec. 7M4, Business affl holessbn Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such pnrjccts with a Contractor(s) licenscd pursuant to the Conuactor's License law). -IantexemptunderSectiott-,B'&P.C.fortlrisreas<rtt.I l^. ^. W0 R K l',1 t(S' COM I'liN SA'l' I 0N DECLARATION I hcrcby aflirm under pcnalty of pcrjury one of thc lbllowing dcclarations: _l have and will nnintafur a Certilicate of Consent to Self-lnsure for workers'compensation, as provided for by Section 3700 of the [:bor Code, for thc perfornrance of the work for which thc Jrcrrnit is issucd. _l have anrJ will nnintailr workers'Section 3700 of the Labor Code, for the grcrfonnance of ,carricr arxl gxllicy nunrbcr are:the work for this 1^-rrnit is a oo t ?8-\ ^5 Policy U t7 q1 t 0\zt -l ccrrify that in the lrcrlirrnrance of tlrc work for whiclr this permit is issucd, I shall not cnlploy any pcrson in any manncr so as to bccornc subjcct to thc workers' compensation laws of Califomia. and agrcc that if I should become subjcct to the workers' conryrnsation provisions of Section 3700 of the l-abor CrxJe, I shall, forthwith conply with those provisioru.. WARNING: Failure to secure workers'compensution coverage is unlawful, and shall subject an employer to criminal pcnalties and civil lines up lo one hundred thousand dollars ($100.000t. in addition to the cost of compensation, danuges as provided for,the Section 3076 of thc [:tnr Cedc- intc'rcst and attorncy's ll'cs. ^-A r ,^,". 1t/t6 / 20 ooo,,*,.t- I hereby affrnr under pnalty of perjury that I anr licensed untler provisiorr of Chapter 9 (conrmencing with Section 70m) of Division 3 of the Businc.ss and Professions Code. arxl my licensc is in full forcc arxl effect. License ,liLq'|cr{,4 CONSTRUCTION LENDING AGENCY I hcrcby allirm undcr pcnalty of perjury that there is a construction lcnding agerrcy for thc pcrformance of thc work ltrr which this pcrrnit is issued (Sec. 3097, Civ. C.). [.cnder's Name: I-rntler's Address: APPLICANT DECI,ARATION I hcreby affrnr untlcr penalty of perjury unc of thc folklwing dcclarations: Dcnxrlition Pcrnrits-Asbcstos Notification Fedcral Regulations (Tillc 40. Pan6) -Rcquired l.cttcr of Notification I ccrtilv that thc &^nr.y,r,* I ltavc federal rcgulations rcgarding asbcstos rcmoval arc nol applicable to this projr:ct. rcatl this application and stulc that thc ahrve ordinanccs and State laws rclating to building above mcntioned pmperty for Applicant or Agent Pcrnrilee a Licensecrass: Lt o/ cqg /F o^,",'ll/ ( b/ Lo