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ELECTRICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG COMMENTS OWNER BUILI)ER DEI,(:ARATION Ihoebya[firmundopenaltyofpojurythatIanexemplfromtheContraclo6 LicffscLawforthefollowingre6on(Sec.70-1L5 Businas md Prof6sion Code): Any City or County which rcquile a ponit to constmct, aho, improve. deprolish or rqrir ryry slruclure. prior lo ils issuance, also requirG lhe applicant for such pennil lo file a signed statmml that he or she is licssed pursuant to lhe provisions ofthe Conlraclor's l.icensed hrv (Chaplq 9, Comntencing wilh Seclion 7000 ofDivision 3 oflhe Business and : ProfessionsCode)orlhatheorsheisexemptthsefiomandtheb6isfortheallegedexonption. AnyviolationofS(lionT0.ll.5byany applicant for a pmrit subjects lhe applicant to a civil penalty ofnet more than five hundred dollms ($500). I. o orvner of lhe proFrfly, or my ernployG with rvaga r their mle compmation. rvill do the work md lhc studue is nol intoded oroffsedforslc(Se.7044.BusincsandProfesionsCode:ThcContractor'sLicmeLawdo6nolapplyloeotrntrof lheproperty whobuildsorimprovsthqsn,@dwhodo6suchworthimselforheselforthroughhisorherownemployes. provided that such improvanfits m not intmded orollsed for sle. l[ horvo'q. the building or improvenmt is vrld uithin one 1w ofcomple,tion. the Orns Buildq will have the hrdm ofproving that he or she did not build or improve the rtropqty for thc puryn* of gle). , _1. a ownr ofthe poperty. an exclusively contracting with licmsed conlraclore to construct the Froject (Sec. 7M4. Busins and ProftssionCode:'lhcContractor'sLicenseLalvdo6notapplyloanorvnsofproJmtyrvhobuildsorimprovolhtrsn. anrl who contracls for such prcjets rvith a Conlracto(s) licoscd pursuant to the Contractor's Liccnse Larv). I an €xempl unds Setion-, B. & P.C. for this rrcon. Date:_- _,Osner: lVORKERS' CONIPENSATION DECLARATION I hcreby allirm undo penalty ofpojury one ofthe follorving delarations: lhaveildwillmaintainaCenificateofConsmltoSclf-lnsureforrvorkss'compqrsation,o providedforbySKtion3T00ofthe t,abor Code. for the pofonnance ofthc work for which the pmnit is issued. Ihaveandrvillmaintain*orkm'compcroalioninsurance.6 requiredbySetion3700oftheLaborCode.forthepsfonnanceof the \rcrk for which this pmnit is issued. My rvorkm' compmsalion imurancc cmio md policy numbo re: Caris:- Policy Number:-Expires: I cffiry lhat in the perlbrmance ofthe rvork for which this permit is issuetl. I shall nol employ any pqson in any milner o m to become subjat to the work6' cornpeNalion laws of Califomia. md agre that if I should becorne subjat to the workqs' cornpsation provisions of Sction -1700 of lhe Labor Code. I shall. fonhwith comply with thos provisions.. WARNINC: Failure to wure rvorkers'conrpmxtion covenlic is unlawful. and shall subjct m mployo to oiminal peraltis and civil fins up to one hundred thosand dollds ($100.000). in addition k' tk cost ofcompensation. damages as provided for Ihe :";-x[Lr-TT:'f\nnou0, .lt-"ffi**I hereby aflirm under pmalty ofpqjury that I an licosed undo govision ofChaplfl 9 (commencing with Se.tion 7000) otDivisbn 3 of the Businss md Profesiom Codc. md my license is in full force md effecl. l-icense Class: *.. Iil,IJ Nurnbcr: (-onlraclor: (.0NS I'RUC'TION LIiNDINC ACi:N('Y issucd (Sa. 3097. Civ. C.). lrndo s Narne: _ Ltrdtr s Addrsr _ APPLICAN'I DECLARATION I hecby affmn undo penalty ofperjury one of the following decla ations: Itmolition Pmits-Asb6tos Notification Fedaal Rcgulations ( l itle 40. Pd6) _-Required tdttr of Notification I cerlify lhat the fcderal regulalions regading asbetos ronoval ue nol applicable lo lhis projecl. I ccrtity lhat I have rcad this application md statc thal the atnve iilfomati(rn is cor(l- I agre to comply : reprdcntatives oflhis City wilh all Cily and ('ounly and (bunly to ents upon theordinances aDd Slate Laws rclaling to atnve menlioned prop€rly for inspetion Applicsnt or Agent I'crtrlilce ilatrrc (l,rinl): constructfu n. and hcreby aulhorizc -*,",llzl t) Site-Work Underqround Pole Bases Liqht Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Building Under Slab / Floor Bondinq / Groundinq / UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rough) Ceilinqs (Hard & Soffit Rouqh Ceilings (T-Bar Rough) Meter Release Rough Service Meter /A. FINAL \-1,-r "7n x){fN\ Notes, Remarks, Etc.