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ELECTRICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG. CQMMF.NTS 1---------------------;--;-------+------➔-------S it e -Work Underground Pole Bases Light 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 (Rouqh) Ceilinqs (Hard & Soffit Rough Ceilings (T-Bar Rough) I I Meter Release I h Rouqh Service Meter I - FINAL Notes, Remarks, Etc. OWNEI! IIUI LDEI! DELCA l!ATION .• I hereby nffinn undc.-r pcm1lty o r pe1jury that I mn exempt from the Co111rncto rs· License Law fo r the fo llowi11g rcn so11 (Scc.7031.5 Bus in1.-ss and Pro fes sion Code): Any Ci1y or Co1111ty which requi res a permit to const ruct. alter. imp rove. demol~l1 or repa ii ,my structure. prior to il s issmmce. also requires t he a pplicant fo r such permit to file a s ig ned statement that he o r she is licensed o ursu ant 10 the provisions or 1he Contrnctor·s Licensed Law (Chapter 9 . C onunencing with Section 7000 of Divis ion 3 of 1hc Bus iness and Professions Code) or that he or she is exempt therefrom and t he basis IOr th e alleged e,xcmplion . An y vio lation of Se ct io n 70.' 1.5 by any applicant for a pennit subjt.--cts the app licant to a ci vil penalty of no t more than fi ve hundred dol lars ($5 00}. ·--r}__1, as owner o f the prope11y. or my employees with wages as their so le co mpensat ion. wi ll do the work and the stnicHm,: is no l intended or o fTered for sale (Sec.7044. Business and Professions C'o de: The Contrac1or's License L.iw does not apply to an owner of the propt'Tty who bui lds or improves thert.'On. and who docs such work himself or hersel f or through his or her o wn em ployees. provided th,,t such im1>rovt.inents are not intcndt.."<l orofTcrcd for sale. If. however. the build ing or improvement is so ld wi1hin one year of cumpk:tion. the Owner Buildt.i· will have the burden of pro ving thal he or she did not build o r imp rove the pro pe11 y for the puq:,oseof sale). _I. as owner o f the pmpei1y. am c .xclu sivcly contract ing with li censed contracto rs to co nst111c1 lhe project (Sec . 70-14. Business and Pmfcss io n C'odc : T he Co ntracl or's License Law does no t apply t o nn owner of propc11y w ho builds or imp roves 1hercon. rind who conlrncts for such projects with a Cont ractor(s) licensed pursuan1 to 1he Cont rac tor's License Law). _I am e.xempt un der Sect ion, ________ . B. & filct J,o r this rtason. 1>111<: • \ <--1 -lb Own cr:-,C. ·-rt{/{/A,,v-- --~---~~---'-;-\"vo=R7K"E;;\wt,S~' ~C~O~~~IP;:;E°'cN:;;Sc;-Ac;.1;:;.lccOccN.,------------- DECLA llATION I hereby affirm under penally of perjury one of the following dccl:lrat ions: ~' h:l\'e and will ma inta in a Ce1t ificatc of Consent to Sclf.Jnsurc for worh,·s · compens.1tion. as provided fo r by Section 3700 o f 1hc LaOOr Code, for the performance oflhe work for which lhc permit is issued. _1 have and \\'ill maintain workers· compensat io n insurance. as requi red by Section 3700 of1he Labor Code. for 1hc pcr fon nanrc of th e work for which th is pcnn it is issued . My workers· compe nsation insuranc e canier and po licy num ber are : C'mTier: __________________________ _ Polic y Number: _____________________ Expirc s : __________ _ i::ii certify that in t he performance o f t he work for wh ich 1h is pci-mit is issued. I s ha ll 1101 employ .iny person in any ma nner so as to become subject to the worktTs ' compensatio n laws of Californ ia. and agree 1hn1 if I should bec ome subject to lhe workc.,·s' co mpensation prov isio ns ofS<."Ct ion 3700 of th e Labor Code. I shall. f011 hwi1h comply with ll1osc proYi sions .. \~~RN ING : f.ailure to secure workers' ccm1pcnsa tion l'Ovcr:i_gc is,~.11~lmatvfi I. and slrnll subject :m ~nplo)'t::r to t1iminnl 1~m11tics and c1v1l fi nes up to one hundred 1housa nd dollars ($100,000). m add1t10 o 1c cost of co rn pc nsa1 1011. damages as prov1ded for lh e Section 30i 6 of the Labor C'od~. in terest and att orney's fees . . . ..-'- Dale: • l '1--j -f 0 Ap1ilirnnl: )(._ Ll-,C~'E"',N~S"E,-.D-(-;;;:JO~N~-1~-R~A...,C"':·1"''0"1,-! ____________ _ DECLAl!ATION 1 hereby affirm under penalty of pe1jur y that I am licensed under provi~ion o f Cha pter 9 tcommencing. wi th Section 7000 ) of Division 3 of the Busi ness nnd Professions Code. and my license is in full force and effect. License Class: ______________ License Number: _______________ _ Dale: ____________ C ontrnclur: _____________________ _ CONSTltllCTION LEN DI NG AG EN CY I hereby nffirm under penalty of pc~jury timt there is a consl m clio n lending agency for t he perfonnan cc o ft he work fo r whi d1 this pc.,in it is issued (Sec. 3097. Civ. C.). Lender's Name: _________________________ _ Lender's Address: _________________________ _ APPLICANT IJEC LAl!ATION I hln:by afiinn under penalty of perjury o ne of 1hc fo ll owing declarat ions: Demo lit ion Permits.Asbestos Notifi cat ion Federal Regu lations (Tille 40. Part 6 ) _Required Lctterof N01ificatio n _I cei1ify that 1he federal regul.11ions regarding asbestos re moval arc not applicable-lo this project. ~ I> ~I cci1 1fy tha l I have 1cad tlus applicatio~~l and , te that the nlxn e mfonnatron 1s correc t I agree 10 comply \\ 11!1 all C'Hy and County ord in ances and Slate Laws relatmg 10 build ing 1 1uct1011. and he1eby au thorize 1cpn:sentat 1,es of this C ity and County 10 enl cr upon 1he abo .. c mentioned property fm ms pecllon pm t-----------------------------------------------------1 A1>p lic:111torAgc111 Signat111 e "ii(. -D:1te ,. / ]_ -t -jb Pe rmitce name (print): \c.