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ELECTRICAL.I NSPECTOR RECORD <br />Rev.08-07-2015 <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hereby aflim undo penalty of perjury that I an exmpt fiom the Contrado6' Licffi ljw for the following rwn (Sc.7031.5 <br />Busin6s dd Profsion Codc): Any City or County which rcquire a po'mit to coBtruct, aho, improve, dmolish or repair oy <br />stru(1ue. prior to its issumcc, also requirG thc applicant for such pemit to file a signed statcmflt that hc or she is licffcd pmuant <br />to the prcvisioN of the Contractor's Licensed Law (Chapttr 9, Comnencing with Sstion 7000 of Divfuion 3 of the Business @d <br />ProfcssionsCode)orthathcorsheisexemptthqefiommdtheb6isfortheallegedexmption. AnyviolationofScaionT03l.5byari <br />applicant for a pmit subjsts the applicant to a civil penalty of not more the five hundrcd dollus ($500). <br />_1, c ownq of the prop€aty. or my employees with wage o their rcle compensation, will do the work md the slruclue is not <br />intoded oroffcredforsle(Se.T044,BusinssmdhofGsionsCoderTheConlraclor'sLicenscLawdo6notapplytoilowntrof <br />thepmperly whoboildsorimprovGtha@[mdwhodo6suchworthirnselforhwlfortkoughhisorhaowncmployec, <br />providcd that such improvmfits @ not intflded or offqtd for sle. If. howwd. the building or im[rcvemmt is eld within one ]q <br />ofcomplaion. thc Owns Buildq will have the burdm ofproving thd he or she did not build or irnprove the prcpoty for the purpos of <br />sle). <br />_1. 6 owner of the p(opmy. m excluively contracting with licrued contracton lo construcl the projet (Se. 7044. B6ins <br />and ProfsionCodetThcContractor'sLiccnseLawdo6notapplyloeownsofpropertywhobuildsorimproveslhsmn, <br />and who conlracts for such projects wilh a Conlncto(s) licmed puEum( lo the Contractor's Licme taw). <br />I m excmpt undq Setion-, B. & P.C. for this reson. <br />WORI(ERS' COM PENSATION <br />DECLARA'TION <br />I hcreby affirm undo peralty ofpejury one ofthc following dwlaratiom: <br />_l havc ud will maintain a Cealificate of Consot to Self-lNurc for workqs compwlion. 6 provided for by S{tion 3700 of the <br />labor Codc, for thc psfomilce of lhe work for which the p6mit is i$ued. <br />I have and will maintain workers'Section 3700 oflhe Labor Code, for the pofcrnnuce of <br />the work for which pcnrit is cmio ad policy numbo ue: <br />Policy Numbq: Expires: <br />_l ceniry that in the psfomancc of the work for which this pmit is issucd, I shall not mploy my person in my mmno <br />s 6 to becomc subjet to the wort6' compsMtion laws of Califomia ed agr that if I should becomc subjct to the <br />workm' compmation provisiom of Scction 3700 of the t bor Code I slull. fonhwith comply with tho$ prcvisiom.. <br />WARNINC: Failure to sue workem' compmation covqage <br />civil fue up to one hundred thouwd dollffi ($100.000), in r <br />S€tion 3076 of rhe Labor Codc inlqGl ad 8llorcy's fe6. <br />is unlawful. and shall subjct an mploys to oiminal psaltiG md <br />addition to the cost of compensation. dmagcs c provided for the <br />o^n 2 -lo -2-2-I <br />DECI.ABAIION <br />I hoeby affrm undc poahy of ptrjury that I m licens€d unds provision of Chaptc 9 (commcinS with Scclion 7000) of Division 3 <br />of the Busins md Prcfsiom Code, ad my licre is in full force md cffct. <br />l-i"*"ct*, <br />t E LiccnseNumbq:'1o9741 <br />CONSTRUCTION LENDTNG ACENCY <br />I hmby affim undo penalty of psjury thd th6c is a conslrudion lendhg agmcy for thc pcfomilce of thc work for which this pqmit is <br />issued (Sc. 3097. Civ. C.). <br />[,mds's Nme: <br />Lqda's Addre: <br />APPLICANT DECI-ARATION <br />I hoeby affim unda paalty ofpcrjury one ofthc following dslaations: <br />Demolition Pemits-Asbestos Notification Fedsal Regulations (Title 40, Pat6) <br />_Required Lata of Notification <br />with all City and County <br />md County to mts upon the <br />above mstioncd prcperty for inspcoion puposa. <br />Applicant or Agcnt <br />l'crnrilcc nailrc <br />o"",2-1o'Z"-Zp <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bondinq / Groundinq / 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 />I <br />Rough 4,lo 7t)i-Xkr ?*)tP'1 lbot<,rl rt <br />Service Meter rl <br />ll \,I <br />FINAL L vll/>,6Ly57 <br />Notes, Rpmarks, Etc I I <br />l{ <br />D'H <br />All n rtN o Dr gb/-6-Zr