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ELECTRICAL.INSPECTOR RECORD <br />Rev.0B-07-2015 <br />APPROVALS DATE !D/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hoeby a[hrm undcr poalty of ptrjury that I an exempt from thc Contracto6' Licflse law for the following rwn (Se.7031.5 <br />Businos and Profssion Codc): Any City or County which rcquire a pomit to construct, alta, improvq donolish or repair ay <br />structue. prior to its issuilcc, also requirG lhe applicilt for such p€mit lo file a signed statmmt that he or she is licemed pmumt <br />to lhe provisions of lhc Contractor's Licensed Law (Chaptry 9, Commencing with Setion 7000 of Division 3 of the Business md <br />PrcfcsionsCode)orthatheorsheisexemptthdefiomedlhebasisfortheallegedcxemption. AnyviolationofSdionT0Sl.5byanj <br />applicant for a pmnit subj(ls lhe applicut to a civil penalty ofnot morc the hve hundred dollus ($500). <br />I, m omo of thc propeay, or rny employe with rvaga a their ole comp€nstion, will do the wort ed the structw is not <br />intoded or olfsed for ele (56.7044, Busin6s ild Prof6sioN Code: The Contraclor's Licme Law do6 not apply to m om6 of <br />the prcpqly who builds or improve th6@n, od who do6 such work htnself or hersclf or through his or ho own employee, <br />providedthatsuch improvmots@rctintodedoroffqcdforgle. lf.howos.thebuildingorimprcvffitisrcldwithinoneyw <br />ofcomplaion. the Orvnq Buildq will havc the hrdm ofproving thd he or she did not build or improve the prcpaty for the purpor of <br />slc). <br />_1. a omq of the propqty, m exclusivcly conracting with lic$ed contractoG to constncl the projct (Se. 7044. Buine <br />ud ProfsionCode:TheContractor'sLice$e[,awdo6notapplytoeownerofpropstywhobuildsorimprovcsthereon, <br />ad who contrads for such projets with a ContEcto(s) Iicmcd puN@l to the Contrador's Licmc law). <br />-l <br />m excmpl undtr Sectioo-, B. & P.C. for this tson. <br />Ihlr <br />WORI(ERS' COMPENSATION <br />DECLAAATION <br />I hereby affim undo penalty ofperjury one ofthe following d4luatioN: <br />_l have ud will maintain a Cstificatc of Co66t to Self-lNure for workm' compsmtion, u prcvidcd for by Sfftion 3700 of thc <br />labor Code. for the pofomilce of the wort for which thc pqrnit b isued. <br />fl hare and *ilt mainlain workm' compeGation imurance, 6 rcquired by Sction 3700 of thc Labor Code. for the pqfomace of <br />Ihe work for which this permil is iscd My work6' compqEation iNuecc @is ad policy numba ac: <br />A <br />2qoPolicy /e'q- 2ozo <br />_l ccdiry that in the pqformance of the work for which this psrnit is issucd, I shall not mploy any peson in any mmno <br />rc a to become subjccl (o the work6' compemation laws of Califomia, ad agre that if I should becomc subjat to the <br />workm' cornpmation provisiom of Srtion 3700 of the Labor Codc. I shall. fonhwith cornply with tho* provisions.. <br />WARNINC: F-ailurc to sue workos'compmsation covtrage is unlawful. md shall subjat m mployq to qirninal pemhie md <br />civil fines up to one hundred thousmd dollds ($100.000). in addition ,thc cost of compcNation. dmagcs o provided for thc <br />Ssriotr 3076 of the trbor Code. intgcs md attomcy's f6. <br />DNle:l-l?-tozo <br />I hcrcby affirur undcr pcnally of pc{ury thal I am liccnsed under provision I (connncncing with Seclion 7000) ol'l)ivisior.l <br />of thc Businw md Profsioro Code. md my licoe is in full force ed cff6t. <br />Liccnse ctass: A-(f,[-icense Numbcr:/ oo q,/ €L <br />- ?o?r).)s <br />CONSTRUCTION LENDING ACENCY <br />I hseby affnn undcr Fmalty of ptrjury lhat th6e is a construction loding agocy for lhc psfomuce of the work for which this psmit is <br />issucd (56. 3097, Cliv. C.). <br />lrndq's Nurc: <br />Lcndq s Addre: <br />APPLICANT DECLARATION <br />I hdtby affm unds pcnalty ofpajury one ofthe following dcluations: <br />Dcmolition P6mits-AsbGtos Notification Fedsal Regulations (Title 40, Pan6) <br />Required ldts of Notificalion <br />_l cfiiry thd lhe fedaal rcgulaliom rcguding cbctos rmoval ac not applicable to this prcjtrl. <br />state that thc above infomalion is corecl. I agre to comply with all City and County <br />authorizc reprGcntativG oflhis City md County to otq upon the <br />above mmtioned prcperty for iropection purpose. <br />Applicatrt or Agcnt <br />Permite name (print): _ <br />urd <br />o1e2- <br />0? -tQ'2020 <br />Site-Work <br />Underqround <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bonding / Grounding / 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 Rouqh <br />Ceilinqs (T-Bar Rouqh) <br />Meter Release <br />Rouqh <br />Service lvleter ?I <br />FINAL '1//t,/?f) A kqi ) <br />Rema Etc. <br />()rinerl