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ELECTR!CAL.INSPECTOR RECORD <br />Rev.08-07-2015 <br />APPROVALS DATE ID/S!G.COMMENTS ()WNT'R BUII,DER I)1]I,CARATION <br />I hcrcby affrnr under pcnahy of pcrjury that I dtr exenpt fronr lhe CbntmctoN' Licensc Law for thc following caetr (Sft.7031.5 <br />Busincss and Profcssion Codc): Any City or County which rcquircs a pcmit to construct, altq, improve. demlish or rcpair my <br />struclurc, prior to ils issuancc. also rcquires thc applicnil for sucl ltnril k) fik a siSned statarftnl that lr or she is licco*d pursu{rl <br />lo th( pmvisions of thc Contraclor's Liccnscd lrw (Chaptcr 9, Comrncncing with Section 7fiyJ ot Division 3 of thc Busincss and <br />PrcfessionsCode)orthatlEorsheiscxcmpttherefronraildtlEbasisfortheitllegedexemiliotr. AnyviolationofS{licn703l.5byany <br />appliconrforapeflnitsubjectsthe cpplicxnttodcivilpcnaltyofnolmreth&nfivchundrcddollars($500). <br />_1. &\ owncr ol the prolrny, or my ernployces with wagcs as their solc compensalion, willdo thc work and thc stNft is mt <br />interklcd or offarad tor sala (Sd.7(N4. Busincss and Pmfcssions Codc: Th€ Conllactor's Liccn* Law d@s not apply lo flr owrcr of <br />tlE lmp€ny wlD hoildi or irwoEs llH$& uxl wlD d(ur such work himself ot lErself or throuSh his or her own enployces, <br />provided that such improvcrmnts ec not iilcndcd or ollcrcd for salc. ll, howcvs, OE tuilding or ftprovcmnt is sld within orc )r{ <br />of conlplctiol (he Owrer Buik-ler will havc the bonlcn of pnrving tha hc o( s]E di.l mt buil.l or ifipmvc thc pmpqty for thc puq[s of <br />sale). <br />_1, as owncr of the prcpeny, um cxclusivcly contrac(ing wilh liccfisd conhcloB to construcl th. prcFct (Scc. 7044. Businc$ <br />and Prolisur Code: The Contrackrr's LiceDse Law dcs not apply lo an owDer of propcny who builds or improvcs lhereon. <br />atrd who contracls for such prejccts wilh a Coilmcto(s) licenscd pursuet to thc Contrador's LiceNe [lw). <br />-l <br />mr erenlt under Section-, B. & P.C. tbr tbis reason. <br />Dale:- <br />lYoRKI.;RS' Col\l l'HNSA'r'lON <br />DI:CLAR,\TION <br />I hcrcby affirm undcr pcndlly ofpcrjury onc oflhc l'ollowitrg dccl4atios: <br />_l have md will nuinlair a Cefliticalc of CoDsent m Self-lnsurc for workcrs' conrpensation, as prcvided for by Scction 3700 of thc <br />Latx)r Codc, for thc trcrfoilMmc oflhc uork lor which lhe pcrDil ir issucd. <br />_l have an{l will nrairilail workers cotrrpensali()n insurarce. as requircd hy Secti<m 3700 oflh€ tik)r Codc, for the lErf()rDurrc of <br />thc work lbr wlrich this lrcrnit rs i\suc(l. Mj comfEBation irrsur@c cuicr arxl lDlicy numher dc: <br />C d.1/.t (/11 cl <br />ZZr/Policy <br />_l cc(ili thar i[ thc Frlinnancc ol thc work for vhich this ]rcrnil is issucd, I slrall not cnrploy any pcrson in any manncr <br />m astobccorrcsubjcctlothcworkcrs'conpcnsrtioDlawsoICalifornix.andaSrccthatiflslnuldbccorrcsubjccttothc <br />workers' conucnsalion provisions of Section 1700 of th. tnbor Code, I shall, fonhwith conlply with thos prcvisiorN.. <br />WARNING: Failur. to scure workcrs' <br />civil lines up k) onc huDdred thousand <br />compcnsation covcrdgc <br />dollars ($100.000). iD r <br />is unlawful. and shall subjcct an amployer to crhninsl pcnaltics <br />Iaddition to lhe cost of danrages as providcd for <br />a(orrcy's fccs.x <br />I)I]CI.ARA TION <br />I hcrcby affirnr unrJcr petralty of perjury thal I anr licensd under prcvision ofChapter 9 (cotrrmencinS with Section 7U)0) of Division l <br />of lhe Busincss aDd Professions Code. and my license is in lull forcc and effect. <br />License <br />7V2 6?b <br />2o <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby allirm undcr pcnaky of pcrjury that thdc is a construc(ion lending agercy for thc IErformmc of(hc work lbr which this pcrmit is <br />issucd (Scc. 3097. Cir'. C.). <br />lrndcr's Nanrc: <br />[rndcr's Atldrcss: <br />ruNLpEe!&UtlN <br />I lmby aJt'imrundcr pcnalty of pcrjury onc of lhe following delarations: <br />Dcnnlition Pcrmits-AstEskts Notification Fcderal Rcgulations (Titlc 40, Pd6) <br />-Rcquircd <br />Lcttcr of Mlificalion <br />_l cc(ify lhd lhc fcdcral regulalions rc8ddins asbcstos rcmoval de not applicablc to this projet. <br />B-l cmify rUr t tuvc rcrd this applicalior axl stalc tlul the abovc infornulion is corcct. I a8rc to conrply with all City and County <br />ordinanccs and Statc laws rclating h building hcrcby authorize rcprcsntativcs ofthis Cily and County to cnts uF)n thc <br />alxrve mentioned prrpe(y for inspectt)n <br />Applicant or A[ctrl <br />I'cmilcc nsnrc t ^,",2/r/ao <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm i Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bondinq / 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 />Ceilinqs (T-Bar Rouqh) <br />Meter Release <br />Rouqh <br />Service lVleter <br />F!NAL 6-10 -za },\fl-)0 <br />Notes Remarks Etc.I <br />I