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ELECTRICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG. COMMENTS OWNER llUILDER D ELCARATION I hereby affirm under penalty of perjury that I mn exem pt from the Cont ractors· l..icen!-e Law fo r the following re:tson (S ec.703 1:1 Site-Work Business and Professio n Code): Any City or Co un1 y which requires a permit to co nstruct. ahc1·. improve. demolish or repair any structure, prior 10 its issuance, also req uires the applicant for such pcnnit to fi le a signed statement that he o r she is licensed pursuant Underqround to the provisions of the Controctor·s Licensed Law (Chapter 9. Co mmencing with Section 7000 o f Divis ion 3 of the Business and Pole Bases Professions Code) or that he or she is exempt therefrom and the ba.,;;is for the alleged exemptio n. An y violntion of Seclion 7031.5 by any applicant for a pennit subjects the applicant to a ci vil penalty of not mo re than five hundred dollars ($500). • Light Standards _I, as owner oflhc propcr1 y. or my employees with wngcs as their sole compcnsa1ion. will do the work and 1he structure is not Spas, Pool, Fountains intended or orrcrcd for sale (Scc.7044, L3usiness and Profe5sions Code: The Contrac1 or's License Law does not apply to an o,,"ner of tht! propt.i1y who bu il ds or improvt'S thc.:.,eon. and who does such work himself or herself or through his or her own e111ployees.- Siqns (monument) provided that such improvt.incnts arc nol imcndetl or orrered for sale. If. however. the bu ild ing or irnprorement is sold wii't1i11 one year of complet ion. 1hc Owner BuikJcr wil\ h.tvc the burden of proving that he or she d id not build or improve the propt11 y for tht puqXJsc of sale). Life Safety /Low Voltage _I. nsowncr of the propci1y. am exclusi vely contract ing wil h lict.'llScd contractors to constn1ct the project (Sec. 704 4. Business Fire Alarm / Dampers and Pmfess io n Code: The Conlrnctor·s License La w does not apply lo an owner ofp1·o perty who bui lds or improves tl~ereon. and who con1rnc1s ror such projects with a Contrac101·(s) licensed pursuant 10 the Contraclor"s License Law). Communications Cable _I am c;u.'.'mpt under Scrtion • B. & r.C. for th is reason. Date: Owner: Building WORKF.RS' !;O~IPENSATION IJF.r LAl!ATION Under Slab / Fl oor I hereby affirm under penalt y of pt"ljuryonc oflhe fo llowing declarations: Bondinq / Grounding / UFER _I have and will ma inta in a Cc11 ifica1e of Consent lo Self-Insure for wo rkers ' compensatio n. as provided for by Section 3700 o f the Labor Code. for the perfonnance of the work for which the pennit is iss ued Transformers _I have and will ma intain workers' compensatio n insu rnn ee. as required by Sect ion 3700 of the Labo r Code. for the perfonnance or Torqueing ~:T~:::k 6,~t:s;7; is ~i;;;vz· co1~n~1S;•~;;;a~•; po li?~~;e/? Sub-Panels • V? ,_ . ' -, \_ '> ,J, /I 7 Air Conditioners Polic y Number C s I 5_{)_~µ1_/ 8 fapires: a ~ '.,{6 . Roof Too Equipment _I ce11ify that in t he performance of the work for wh ich 1his permi t is issued. I shall nol employ any pers on in any manner Factory Wired Unit so as to become subject to the wu rkcrs· co mpensation laws of Cali fo rnia. and agree 1hat i fI shou ld become subject 10 the workers' compensat ion provisions of Sect ion 3700 oflh c Labo r Code. I sha ll , fort hwit h comply with I hose provisio ns .. Wal ls (Conduit) WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subject an employer to criminal pt.."lm!tics and Walls (Rouq h) civil fines up to one hundred thousand dollars ($100.000). in ad it ion to the cosl of compe11s,11ion. damngcs .t s provided for the Ceilinqs (Hard & Soffit Rouqh Section 3076 of the Labor Code. in terest and attorng:cs. I I 1,, -r;-. A,.... < Ceilinqs (T-Bar Rough) /7.,,, 't:rll-=>-S-)b rv .l::;6)..1-~ </ Date: J/£ f __ '1,.6. Applica t: ~ LI E NS!l!J •~• NTRAf:TOll Meter Release , r ' -UllCLARATION I hereby affirm under penalty of perjury that I am licensed under pro vislon of Chapter 9 (commencing with Section 7000) of Divisi on 3 of the Business and Professio ns Code. and my license is in full force and effect. Rough License Class: .. 5 Licer1.sc N u 111 bcr : ~ .Q Service Meter / I Date_;f.1_'/1J..-1c -.J._L Contracto;b --/.L ¥---/21 ch/ s· FINAL 1/vf '/q; <" ¥--1l..1 ~-0 Notes, Remarks , Etc. ' CONSTRUCTION LEN DI NG AGENCY I hereby affirm under pen.1\ty of perjury thilt tltt:re is a constnict ion lending agency for the perfonnance of the wo rk for which this pt"lln it is issued (Sec. 3097, Civ. C.). Lender's Name: Lender's Address: t;r r u r ANT Dll!;LARA TIQN l hereby affinn umlcr pena lly of pc1jury 0 11c of the fol lowing. dcclaral ions: Demolition Pennits-/\sbestos Not ilicat ion f ederal Regulations (Tit le 40, P.1116) _Required Lett er of Notificat ion _I ct.'Tt ify tha t the federal regubt ions regarding asbestos removal are not applicable to this project. _I ceit ify th at I have read th is appli cmf ~i state that t he a bo\'e in fonnm ion is co1Tcct. I agree to comply with all City and County ordinnnccs and State Laws relating to bu d 1g constmction. and hereby authorize representatives of this C'it y and County to entli upon tl1c above ment ioned propelty for insp71io1 pu ses. G A pplicant or Agent Sign a(n~ f-1;{' .. h l)a (c:_&i/i/---/ 5"" 1 - Pcrn1itec n11111e(p r int): -d..---'L(, I) f.:!,...,, ni:• c:-; ')f'H i~ J ✓