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ELECTRICAL.INSPECTOR RECORD <br />Rev.08-07-2015 <br />APPROVALS DATE ID/SIG.COMMENTS OWNI.]R BUILDER DI]LCARATION <br />I hcrcby affrnl undcr pcnalty of p€rjury that I dil excmpt from the Cbntraclon Licensc liw for thc following Een (Se.7031.5 <br />Busincss and Prolcssion Codc): Any City or Couily which rcquircs a pcnnil lo cons(ruct, sltq. ihprovc, demlish or repair any <br />strucluE, prior b its issuancc. also rcquiEs the applicail foa such frcmil ro fih a sigrcd slatcmnt thst lE or shc is licctl*d pur$ant <br />lo thc pmvisions ol thc Contractor's l,iccnscd Law (Chapter 9, Cornrnencing wilh Scction 7000 ol Division 3 o[thc Business und <br />Professions Code) or that hc or she is exerDl therefrom and tlB basis for tlF allcged eien{,tiotr. Any violarion ofSection 703L5 by sny <br />applicantforalEnnilsubjststhc appliciDttoacivilpcnaltyofnolrrcrclhanfivchundrcddollars($500). <br />_1. as owncr ol'thc propcny. or rny crnployccs with wagcs as thcir $lc compcnsathn, will do thc work and the structuc is not <br />intcrxled or offered for slc (Sc.7(N4. Business md Profcssions Codc: Thc Conlraclor's Liccnsc Law des not apply lo m owncr of <br />theprcFny wlphoildsorhprowstherqnliodwlEd6suchwoIkhimselforlEr*lforthrcuthhisorherownentployes, <br />providcd that such imprevurcnts @ mt intcrxlcd or ollcrcd for elc. Il, howcrcr, OE boiUing or irprovcmil is eld within one )rd <br />ofconulctfur! thc owrer Builler will havc the burden ofpNving lhd lE or she did Nt buill or imprcvc tlrc pnrpaty for th. purpo* of <br />Mle). <br />_1. as owner of thc prupeny. am cxclusi!cly contractins with liccnsd contrelos m con(rud th. prcjcd (Scc. 7Ol4, Busihcs <br />and E$tlsiDCode:TheContractor'sLicenseLawdoesnotapplyloanownerofpropcnywhobuildsorinrprovesthereon. <br />and who conlracls for such prejccts wilh a Contrack)(s) liccnscd pursutut to thc Contr&lor's Licensc [jw). <br />-lanlexempt!DdeIsecli(ll-'B.&P.c,,oflhisreason-I)at(: <br />UIISEES:SAMIJNSAIIAN <br />DECLANATION <br />I hcrcby aflirnr undcr penalty of pcrjury ooc ofthc t'ollowing decltrationi: <br />_lhaveudwillnEinlahaCenificalcofconsenttoSelf-Insureforworkcrs'conrpe[sation,as prcvidedforbyScctionST00ofthc <br />tatnr Codc, for thc pcrforolec of lhc work lbr which tlE pcruit is issued- <br />151 have and will rDaintah workeB'conrpcNation insursncc, as rcquircd by Sccliur 3700 of lhc tibor Codc, for lhc lErfonBrcc o[ <br />thc work for which lhis pcrnit i3 issucd. My workcrs' compcnsation insurdce c6ier and Frlicy numbcr uc: <br />Policy r-)c-\c'l 2 1'1-/3t I LC) <br />_l ccnify that in tlt lrrlornurcc of tlrc work for which this pcrmil is issucd, I shall not employ aoy person in my IMrcr <br />e aslobcmrcsubjccttolhcworkcrs'compcngionlawsofcalifomia.andagccthatiflslnuHbecorrcsubjecttothc <br />workcrs'compcnsationprcvisiosofScction3T00ofthctaborCodc,ldull,fonhwithcomplyailhlho*prcvisioN.. <br />WARNING: Frailurc to sccurc worlerr'compensation coveragc is unlawful, and shall subjcct an employcr to oiminul pcnahics md <br />civil fmes up b onc hundrcd thousand dollars ($lOJ.lX)o). in additiul to tlE cost of comFcretion, dmugcs as providcd for rh. <br />Scction 3076 ofthc Lahor Co(lc. intcrcst md altorrcy's lccs. <br />D^1", blLlLo nppt*t, *-/ - <br />LrcEli[Lp_eQNI&LCTOR _./- <br />I her.by afltrm undcr p€n{lty ofpcrjury that I an, li".r*,I iiliJiiiiiii?chapt{ 9 (connrncing with Scction 7000) ofDivision 3 <br />of the Business and Prcfessions Code. and rny license is in full forc aRl affcct. <br />Liuensc Nunlber:8E6 l0 r-l <br />,*-, a)? lza aesVtC0ntract0r: <br />CONSTRUCTION LENDING AGENCY <br />I hcreby alliiln undcr pcnalty ol pcrjury that thcrc is a construction lendihg agercy for thc pcrlbrmarce oflhc work lor which lhis pcrmit is <br />issu.d (Scc. 3097. Civ. C.). <br />[rndcr'r Noilrc. <br />[ander's Addrcss: <br />4llJNI.p!,c!&Eq <br />I luehy affim undcr pnalty of pc{ury onc ofthc folkrwing dccluationsr <br />Dennlition Pcrnrits-Asbcsk)s Notification Fcdcral RcSulalioos (Titlc 40, Pm6) <br />_Rcquircd trxcr of N(niri6lion <br />_l cc(ily that thc tcdcralrcgulations rc8ilding asbcstos remvaluc not applicablc to this pmjcct. <br />29f,J cenify rlur I havc read ltus applicalion {d statc tlut ilrc dbove inforrotiotr i5 conm. I agre to conrply with all City snd County <br />ordinanccs ud State l-aws rclatinS to building consmction, and hercby autlnrize rcprcsntativcs oflhis City md County to cnter upon rlrc <br />ubovc rnantioned pft)peny for inspeclion plrposes. <br />Applicant or Agot <br />Itcrnrilcc [smc <br />^.", 3lz/zo <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas. Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor /-\ <br />Bondinq / Groundinq / UFER 4.^Z-z <br />Transformers <br />Torqueino <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouoh) <br />Ceilings (Hard & Soffit Rough <br />Ceilinqs (T-Bar Rough) <br />Ivleter Release tzlu -trx7 <br />Exh L/'o+.fi- P l*rOL I Y4WK <br />Rouqh <br />Service Meter ).-,r4itr <br />FINAL <br />Remarks Etc <br />-7O't I <br />( <br />uilllll'-27-z <br />Y <br />a rrrrr V