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ELECTRICAL.I NSPECTOR RECORD <br />Rev.08-07-2015 <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hoeby affmn undo poralty of perjury that I an exempt from the Contraclo$' Licffi taw for the following rcef, (Se.7031.5 <br />Businss md Profsion Codc): Any City or Couoty which requirG a [srnit to coNtrucl. alt6, improve. donolish or rcpat my <br />structure, pnor lo its i$uecc. also requirB thc applicmt for such p€mit to file a signed statmmt thal he or she is licscd plNmt <br />to the provisions of the Contractor's Licensed Law (Chapl6 9. Comrnencing wilh Setion 7000 of Division 3 of the Busines md <br />ProfessiotrsCodc)orthatheorsheisexcmptthqefiomedthebasisfortheallcgedexmption. AnyviolationofScctionT03l.5byany. <br />applicant for a p@nil subjets the applicant to a civil penally of not more thd five hundrcd dollas ($500). <br />I. o ome of the propeny, or my employ$ with wag6 6 thct sole compemation, willdo the work ild the stmcluc is not <br />intoded or offcred for ele (Ss.7044. Businss md Professions Code: The Contractor's Licme Law dos not apply to il ownff of <br />theprcpqty whobuildsorinproveth@n.odwhodo6suchwotkhimsclforhmelforthroughhisorhroweinployec, <br />provided that such imFmvmols ile not intmdcd or offq€d for slc. If, howwq. the building or improvmmt is mld within one ya <br />ofcomplaion. the Oms Buildq will have the hrdan ofpoving that he or she did not build or improvc the prcps(y for the purpoe ol <br />sle). <br />- _1. 6 owner of thc propsly. m exclsively contracting with liccreed contractoB to coNlruct lhe prcjrct (Se. 7044. Bsins <br />ild Praf6sionCodc:TheConlractor'sLicenseLawdo6nolapplyloilownsofpropertywhobuildsorirnproveslh6@n. <br />and who contmcts for such prcjets with a Conlmcto(s) licsed pureuilt to lhe Coilraclor's Licmse taw). <br />-ImexemptundrS*tion-,B.&P'c.forthisIe6on. <br />Owner: <br />WORKENS'COMPENSATION <br />DECL/IRATION <br />I hoeby affinn undcr pmalty ofpejury onc ofthc following delrations: <br />_l have ud will maintah a Ccnificate of Commt to Self-l6ure for workm' compeEation. o providcd for by S$tion -1700 of the <br />tnbor 9ode, for the rEfommcc of lhe work for which the pqrnit is issued. <br />Vhave md will maintain workm' compemation iGurancc, 6 rcquired by Sction 3700 otthc Labor Codc, for the pafomuce of <br />G work for which this pmit is issued" My workds' compsation imurmie cmio md policy numba ue:rafQM <br />poti"yN"^*,, Ws ft 5o'17tr {d a o E*ptn a <br />_l certiry thal in the psfonnance of the work for rvhich this pomit is issued, I shall nol onploy any pmon in any mano <br />s d to become subjct to the workffi'compsrstion larvs of Califomia. rod agre that if I should become subjEt to the <br />workm' compmstion provisions of Salion 3700 of the Labor Code, I shall, forthwith comply with thos provisio$.. <br />WARNTNC: F'ailure to wuc works'compcnsation coverage is unlawful. md shall subject m mploye to oiminal pqBlti6 ed <br />civil fines up to one hundred thousmd dollm ($l in additioo to thc cost of comp€Ntion. damaga a provide{ for the <br />Sslion 3076 of the tibor Code, intqel ed dlomey's <br />D^1", . o "/,/A//a-) <br />t)t,r( r. \R.\'l IoN <br />I hoeby aflim undcr penatly of pqjury that I an licosod undo provision of Chapto 9 (comocing with S*tion 7000) of Division 3 <br />of the Busins md Prcfsiom Code, od rny licme is in full force md effet.4*?{.C-tOl-iccnsc Numbcr: <br />('onlractor: <br />I hreby affm undo pcnalty of perjury thar th6c is a coNtruction loding agmcy for the pofommce of thc work for which this p6mil b <br />issued (Se. 3097, Civ. C.). <br />Lende s Namc: <br />Lendn s Addes: <br />APPLICAN'I' I)ECI,ARA'IION <br />I hqtty affim undo psralty of perjury one of (he following dsldations: <br />Dcrnolition Pcflnits-Asbstos Notification Federal Regulations (Title 40, Part6) <br />_Required Latq of Notifi cation <br />I difu that the <br />Z*r*rn^rr*'" <br />federalregulatiom rcgading cbctos rmovaloe not applicable to this proj(t. <br />read this application od statc that the above infomation is corect. I agr€to comply <br />fthis Cily <br />with all City and County <br />0d County to mt6 upootheordinancG md Slatc lnws relaling to <br />above mmtioned propcrty for pur[Ds6. <br />Applicant or Ageil( <br />Pcrmite namc M6-5' <br />authorize reprMtativ6 o <br />o*", ) o///ct/b <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bondins / 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 (Rough) <br />Ceilinqs (Hard & Soffit Rough <br />Ceilinss (T-Bar Rough) <br />Meter Release <br />Rough <br />Service Meter a I I <br />FINAL )lpl?-o { <br />Notes, Remarks, Etc.L) 1r, <br />:_> <br />o,*, - d?y'or/u