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ELECTRICAL.!NSPECTOR RECORD <br />Rev.08-07-2015 <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUII,DI'R DTiI,CARATION <br />I hcrcby affrm undcr pcnahy of pcrjury lhat I dil cxcDpt from thc ClontracloN Liccnsc law for thc following casn (Se.?o] 1.5 <br />Busincss and Prol'cssion Codc): Any Cily or County which requires a frcrmit to construct, altcr. improve. demolish or rcpair my <br />structurc. prior k) ils issuancc. also Equircs thc applicuil for sucl pemrit to filc a sigrcd statamnl lhat lE or shc is licered pur$anl <br />lo the pmvisions ofthc Contractor's l,icenscd liw (Chaptcr 9, Comrncncing with Section 7000 ol Division 3 ofthe Busine$ and <br />Professio[sCode)orthrtlEorslEisexenrpttherefromandtlEb&sirfortlrcallegedexenlptiul A,ryviolationofsectioDT03l.5byany <br />applicrntfornp.nn[subjcctsthe applicantloacivilpenaltyofnotmrcthanfivchundrcddollors($5fi)). <br />_1. as owner ol tlrc proFf,y. or nry ernployecs wilh wagcs as lhcir elc compcnsalion, will do thc work and the stMtue i$ ftX <br />intcrxlad or oflcrad for slc (Se.71I44, Business and Prcfcssions Codci The Conua(tor's Licen* Lsw d@s nol apply to m owner o[ <br />tlE pfi)|Ir|y who builds or inprovcs therdnr, ud wlb does such work himselfor herselfor lltrough his or her owo enlployees, <br />providcd that such imlrovcmnts uc mt htcndcd ()r ollcrcd for sh. li txlucvcr. trc buiHin8 or itrprowmnt is sld withitr onc }la <br />of conrplctiorr, thc Owrer Builder will have the burden of prcving llut lE or shc r.lirl mt build or impmvc thc pmpqty for thc pury&s of <br />sJe). <br />_[, as owner ofthe pmpcny, dm crclusi!cly contrilcling with liccnscd contraclors to construct lhc prejcct (Se(. 7Ot4, Businc$ <br />and PNltssioilCode:TheContracbr'sLicetrse[-awdoesnotapplytoanownerofproFnywhobuildsorimprovesthereon. <br />and who contracb for such projecls with a Contracto(s) licen*d pursumt to lhc Contrador's LhcNc liw). <br />-ImrexenrptuDdeIsectioh-'B.&P.c.lbrtlrisreason'lr-r-._ n---.. <br />WORKIiRS' COMPI]NSATTON <br />DECLARATION <br />I lrereby allirm unde! pcnaltyoflcrjury onc ofthc tbllowing dccltrations: <br />_IhavcaMwillnuintainaCcnillcatcofConscnttoScl!:lnsurcforworkqs'crmlrcNation,as prcvidcdforbyScction3T0Oofthc <br />Labor Code, Ior thc pcrfonEncc ofthc work for which lhe permit ir issued. <br />_lhaveandwillruairilaillworkc.rs conrpensati(xrinsurarce.as rcqutedbySecltr[3T00oftheljhorCodc,fortheperfonrtrilreeof <br />tlrc work li)r which this l)crmit is irsued. My worlcrs' conlrcnsatior itrsurdrcc cffiicr and lxrlicy numrLr tre: <br />Policy Numbcr: rpircs: <br />_I ccnily that in thc lNrli)rnuncc of tlr work for whicll this pcrmil is issucd, I shall not cmploy any lErson in any nrdncr <br />so as to bccorm subjccl lo thc workcrs' conlpcnsnlion laws ofcalifomia, end agrcc that if I should bccorre subjcct to thc <br />workers'conrpensationprovisionsofSec(ion3T00ofthetaborCode,tslull,fonhwithco[DlywilhthoFpruvisions.. <br />WARNING: Failurc to sccure workers'compensation covcragc is unlawful, and shall subjcct an anploycr to oiminal pcnahia and <br />civil fincsuploouehundr€dthousarddollars(5100.000).inad<litiontothecostofcompe[salion,ddugesasprovidcdforthc <br />scction 3076 ofthc tlbor Codc. inrcres( md atlorNy s fccs. <br />LICENSED CONTRACTOR <br />I)HCI,ARATI()N <br />I hercby affrrn under penrlty ofpcrjury tlrat I anr liccf,sd under pNvision ofChaptcr 9 (coilurEn.in8 with Scction 70@) ofDivision 3 <br />of thc liusines\ and Prcfcssions Code. ail my liccns€ is in full forc. and cffcct. <br />l-icensc Numbcr: _ <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby aflirm undcr pcnalty of pcrjury that thcrc is a construction lcndinS agcrcy for the performarcc ofthe work tt]r which lhis pcrmit is <br />issued (Scc,109?, Civ. C.). <br />Lcnder's Nanlei <br />[ander's A,i,lrcsr: <br />APPI,ICANT DECI,ARATION <br />I irrcbyaflimrundcr pcnahy ofpcr.jury onc of thc following dcldalions: <br />Dcnnlition Pcrnrils-Asbcstos N(ilificati(,n Ftdcral Rcgulations (Titlc 40, Pd6) <br />-Rcquircd <br />Ldlcr of Notificati()n <br />_l ccnily lhat lhc fcdcral rcSulations rcgddinS asbcstos remval4c not applicablc to this proj@t. <br />_l ccnili thar I luve rcrd this applicatk[ ad stalc that lhc abovc informaliur is coret. I agrcrc to conply with all Cily and County <br />ordinmccs and statc kws rclaling h building constructioG ard hcrcby aulprizc rcprc*otativcs ofthis City ud County to entd uF)n tlE <br />abovc nEntioncd prcpc(y for inspcction purlFws. <br />Aoolicsnt orAsml Sipnsture: Datel <br />Pcmilcc nsme IDfinll: <br />Site-Work <br />Underground <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltaqe <br />Flre Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bondins / Groundinq / UFER <br />Transformers <br />Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinss (T-Bar Rouqh) <br />It/eter Release <br />Rouqh <br />Service lt/eter I I <br />FINAL 7 <br />R Etc.