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ELECTRICAL.INSPECTOR RECORD <br />Rev.08-07-2015 <br />APPROVALS DATE !D/SIG.COMMENTS OWNI,IR BUIl,DllR ITELCARATION <br />I hereby affrrl under pcnalty of perjury that I dil cxcmpt fiofi lhe CbntracloN' Liccnsc ljw for thc followinS rcasoD (Sec.7031.5 <br />Business and Prolbssi()n Code): Any City or County which rcquircs a pcrmit to @nslrud. altq. tnprovc. dcmlish or rcpair any <br />structurc, pri()r to its issuance. also rcquires thc applicuil for such Fmrit lo filc a sigDed slatcmnt llBl lE or shc is liccrNcd pursuill <br />to thc pNvisions ofthc Contractor's l,iccnscd Ilw (Chaptcr 9. Commcncing with Section 7(x)0 of Division 3 ol thc Busincss and <br />ProfessioilsCode)ortl[thcorsheisexeDrptthcrcftomaildtlEbasistbrtlEallegedexenpliur. AnyviolalkDofSectionT03l.5byany <br />opplicantforapcrrnitsubjecrs(he dpplic0nltotrcivilpeniltyofnotmrcthanfivchundrcddollars($5U)). <br />_1, a\ owncr ol thc proJrny, or rny crnployecs with waSes as thcir sle compcngion, willdo thc work and the stMW h mt <br />intcndcd or olTered for sle (Se.7tX4, Business and Pmfcssions Codc: Thc Cootractor's Liccns Law docs nol apply to an owncr of <br />thcprcpeny whobuildsorimprovesllEB)n,ildwlDdNssuchworkhimselforlprselforlhrcushhisorlBrownenlployees, <br />provided rhat such improvcrrcils dc ml intcndcd or ollered for sh. Il. howcwr, tlE buildin8 tr inprovemil is sld wl}lio ore,rd <br />ofcomplclb[ thc Owrer Buiklcr will havc lhe bordcn ofpmving tlu hc o( shc did mt buill or itrpmw t]r pmp<ry for thc purpo* of <br />uk). <br />_1. as owner ofthc propeny, am cxclusivcly contracting with licc[*d contraclors to construct tha prcjact (Scc. 7(x4. Businc$ <br />arxl hofessbr Code: The Contractor's Liccnse Law dtrs not apply to m owncr ofptolrny who builds or improves lhcr@n. <br />and who conuacts for such projccts with a Contracbr(s) licetr*d pursumt to thc Conractor's Licctrsc [2w). <br />-l <br />an.ienpt under Section , B. & P.C. tb! thir reason. <br />WORKERS' COMPI'NSATION <br />DECLARATION <br />I hc(eby nllirnr undcr pcnalty of pcr.iury onc ofthc li)llowing dcclilalinns: <br />_I havc arxl will nuintsh a Cenifiutc of Conscnt o Sclf-lns!rc for workds'$nr{Ensation, as pmvidcd for byScction 3700 of Ih€ <br />tabor Codc, for lhc pcrfornurce ofthc work lor which lhc pcrmil is issued. <br />_l havc aDd will n)aintain workcrs conrpeNali([ insurance, as rcquiEd by Scction 3700 ofthc tibor Code, for lhc fErfomHrec of <br />thc work for which this Frnit is issucd. My workqs' compcNation iNulocc ffiier ilrd lnlicy number ue: <br />I <br />Policy Numbcr: Exptct: <br />_l ccrlify tlut in thc lrcrlirrnrancc of tlrc work for which dris Frnrit is issucd. I shall not cnrploy any lrcrsu) in any manncr <br />so as to bccorrc subjccl to thc workcrs' conlpensntion laws o[Califomia. and agree that it I stnuld bccorrc subjcct to thc <br />workers' conrFnsation provi5ions of Section 3?00 of the libor Code, I shall. fo(hwith conply with lhos prcvisions.. <br />WARNING: Failurc to scure worlcrs'co,npelsution covaragc is unlawful, nnd shall subjact sn cmploycr to ffiminul pcnaltiA and <br />civil fines uP to oDc hundrcd thousa[d dollars ($100.000). itr addition rc the cost of conrpctrsation, danrages as provided for thc <br />Scction 3076 o[the titxtr Codc, int.rcsl and attorrcv's ltes. <br />LICENSED CONTRACTOR <br />DECLARATION <br />I hcEby affrm under Fnalty of pcrjury rhat I anr liccnsql undcr provision ofchaptcr 9 (conurEncing with ScctbD 7000) of Division 3 <br />of the llusincss and Pmfcssions Codc. Anl my liccnsc is in full fore ud cffcct. <br />LiceDse Nunrber: <br />Date:- Cohthclot: <br />CONSTRUCTION LENDING AGENCY <br />I hmby aflirm under pcnahy of pcrjury lhd thffe is a constructhn lcnding a8ercy fo. the perfofiurce ofthc work for which this pcrmit b <br />issuc'l (Scc.309?, Civ. C.). <br />knder's Nanrc: <br />bndcr's Address: <br />APPI,ICANT DECI,ARATION <br />I hucby aflirnrundcr pcnalty of pcrjury onc of thc following declixalions: <br />Dcnrlilion Pcrmits-Asbcsk)s Notification Fedcral Rcgulatioos (Tillc 40, PM(, <br />-Rcquircd <br />bttcr of Notificatioo <br />_l ccnily thal thc ltdcral rcgulations rcgadin8 asbcshs refi)vll ile not applicablc to this projst. <br />_l ccnify thal I luvc rcad tlus applicalioo and statc llut thc aklvc informlion is co[ccl. I agre to conply with all Cily and County <br />ordinanccs and Slate lrws rclating to building construction, dd hcreby authorizc rcprcsenktivcs ofthis City and County to cntq upon t]E <br />ubove rrentioned propeny for inspection purlDss. <br />Applicent or Agmt Date:_ <br />Pcmlle nsme {Drinl): <br />Site-Work <br />Underqround <br />Pole Bases <br />Lioht Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Transformers <br />Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilinqs (Hard & Soffit Rough <br />Ceilinss (T-Bar Rough) <br />lvleter Release <br />Rouqh <br />Service Meter <br />FINAL <br />Notes, Remarks, Etc. <br />a