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APPROVALS DATE ID/SIG.
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab/ Floor
<br />Bondinq / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factorv Wired Unit
<br />Walls (Conduit)
<br />Wall s (Rough)
<br />Ceilinqs (Hard & Soffit Rough
<br />Ceilinqs (T-Bar Rough)
<br />Meter Release
<br />,,
<br />Rouqh {,/1 ·1/{7 ~(• )
<br />Service Meter l
<br />FINAL
<br />Notes, Remarks, Etc.
<br />ELECTRICAL-INSPECTOR RECORD
<br />COMMENTS O WNER UUILDER DELCARATION
<br />I hereby aflirm under penalty of pc~jury that I run exempt from the Contractors· License Lnw for the following rc.lson lSec.7031.5 •
<br />Business and Profession Code): Any City or County which rcq l1ires a pcnnit lo constnict, alter. improve. demolish or rc;.ia ir iny
<br />strncture. prior to its issuance. also requ ires the applicant for such pt::n nit to rile a signed statement t hat he or she is licem;ed pursu ant
<br />to the provisions of the Contractor's Licensed Law (Chapter 9. C'nmmencing with Section 7000 of Division 3 of the Ousiness aqd
<br />Profossions Code) or that ht: or she is exempt thererrom and 1he basis for 1hc nlleged C:'1:cmption. Any viola1 ion or Section 703 1,5 by any
<br />applicant for a permit subjccls the applicant lo a civil pen.i lly of not more t han five hundred dol!n rs ($500).
<br />_I. as owner or 1he prope11y. or my employees with wages as thi:ir sole compt:ns.ition. will do the work and the structure is not
<br />intt.,u.led or offered for snle (Sec. 7044, Business nnd Prorcssions Code: The C'ontractor's License Lnw does not apply to a11 nwner or
<br />the propt..-,1y who builds or improvt'S thereon. a11 d who docs such work himselr or herself or t hrough his or her own employees.
<br />prm1 idcd 1hat such impro\'ements nre not intended or offered ror ~,le. 1r. howevt.·r. th e buil ding or impro,·cment is sokJ within one year
<br />of complelion. the Owncl' Builder will have the burdl.,1 of proving th.it he or she did not buikt or improve the propci1y for the purpose of
<br />s.1le).
<br />_I. a.,owner of1he propei1y. am exclusi\·ely contracting with licensed c011lr.1cfors 10 constmct the project (Sec. i044. Business
<br />nnd Profession ('ode: The Corllraclor's License Law docs ncH apply to ;111 owner of property \\"ho bu ilds or imp roves tl1ereon.
<br />and who contracts for such projects with a Contractor(s) licensed p ursuant lo the Contractor's Licens.e Law).
<br />_1 am e:-.empl ~nder Section ,. B. & P.C. for this rcasan
<br />Dnlc ,J '1 /.I} 9 () ""> l,C';;,,.nc,: X /;?}.re,;;:;?~/___, -
<br />I WQ1.n.-E n s· COl\ll'E~TION
<br />D ECLARATION
<br />I hereby .tflirm under penalty of pc.,jury unc of the fo ll owing declarations:
<br />_I have aml will maintain n Certificate o f Consent to Self-Insure for workers" compensation. as provided for by Scctilln .HOO o f the
<br />Labor Code, for the perforn,nnce of the work for which the permit is issued.
<br />_I h:i.ve and will mnintain workers' compensation insu1T111l·c. as required by Section 3i00 of the L ,bor Code. for the pci·fonmmce of
<br />the work for which this pcnnit is issutd. My workers' compensation insurnncc canicr and policy 1mmber arc:
<br />C'mrier:. __________________________ _
<br />Po licy Number: _____________________ ,Expires: ------·-__
<br />_I certify t hnt i11 1hc perfonn:mcc of1hc work for wh ich th is permit is issue d. I shall not employ any pt.:rson in nny nmtm~r
<br />so ns to become subject io the ,vo rkcrs' compensation laws ofCaliforn i:,, and agree thm if I should become subject 10 the
<br />workers' compensation provisions of Section 3700 of th e Labor Code. I shall. forthwith comply with those provisions ..
<br />WARNI NG: Failure 10 secure wol'ke rs ' compcnsaticm coverage is unlawful. and s hall subject mi employer to t.1·i111inal 1x.1mltics and
<br />civi l fo1es up to one hu ndred thousand dollars ($100.000). in addit ion 10 tu1e n ompensntion. damages as provided for the
<br />Scctio11 3076 ofthJ Labo1· Code. interest and allomey's fets. -/
<br />Dn lc: /' J /.1/ 9 <),, l ~plicn n1:V /--/. '/~/'?/?.-
<br />/ 1A1\1!,NSErl C O NTRACTOR -
<br />'DEC L ARATION ··
<br />I hereby a ffirm under pen.illy of pe1jury tlm1 I nm licensed under provision ()f Chapter() (commencing with Sectio n 7000) of Di\'ision:;
<br />of the Business and Professio ns Code. an<l my license is in fu ll force an d effect.
<br />Li1.:cnsc Class:. ______________ Liccnsc Number: _______________ _
<br />IJate:. __________ _ Co11tntclu1·:. _____________________ _
<br />CONSTRUCTION LENIJINC AGENCY
<br />I hereby ;.1ffin11 under penalt y o f perjury thilt lhere is a cons111..1ction lending agency for lhc performance of the work for which this p<..i·mit is
<br />issued (Sec. 3097. Civ. C .).
<br />Lcnder·s Name; _________________________ _
<br />Lcnd er·s Address: _________________________ _
<br />APPLICANT llECLARATION
<br />I hereby affinn un der penally or perj ury one of the followi ng declarntions:
<br />De moliti on Permit s-Asbestos Notification Federal Rcgulc1tions (Ti1lc 40. Pmt6)
<br />_Required LetterofN01ilicmion
<br />_I ct.11 ify that the !Cderal regufations reg~di ng asbestos remornl arc no t applicable to th is project.
<br />_I CL-iiify th;it I have re:-id this applicnt ion nnd state that th e aOOvc infonnation is co11·1.:ct. I agree to comply with nil City and C'ounl y
<br />01dmancc., and State Lnws 1clatmg to build mg cons~1 n. nd hc1eby authorize 1ep1escntnt 1,cs o f tl11s City nnd Count y 10 en1L'T upo n the
<br />obo\'C menl1oncd propc,1y fo, ,nspccllon pu,poses( / ~ , c... /
<br />Appli cnnlor Agcn l Signaliorc ~ ,~ V??~ IJ,1l c 12 f//2 2u0
<br />Penni1ee name (pr-in t): ;) J ~ /1.--1 ~ AJ?:",,-r .vi.-:.-,., __ ) 1
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