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APPROVALS DATE ID/SIG.
<br />Site-Work
<br />Unde rqrouiid
<br />Po le Bases
<br />Light Standard s
<br />Spa s, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER '5 / ~ / 17 ,,,, .,.Iv(.( q-jq
<br />ELECTRICAL-INSPECTOR RECORD
<br />COMMENTS OWNER BU I L DER l)ELCARAT ION
<br />I hereby affinn under penalty of perjury that I run exempt fro m the Contractors ' License Law for the fo llowin~ renson (Sec.703 1.5
<br />Business and Profession Code): Any Cil y or County wh ich requires a permit to cons1111c1. alter. improve, demo lis h or 11 pai r any
<br />stnictun:. p1"K,r to its issuance. also requ ires t he applicant for such permit to file a signed statement th.it he or she is licensed pursuant
<br />to lh e provisions of the Contractor's Licensed Law (Chapter 9. Commencing wi1h Section 7000 o f Divis ion 3 of the Uusi·1ess and
<br />Professions Code) o r thal he or she is e)[e111p1 th erefrom and t he basis for the a lleged exemption. A11y violation or SeL·t ion 70J 1.5 by any
<br />applicant for a pennit subjec1s the applica nt to a civ il penalt y of not more than five hundred dollars ($500). t
<br />_I. as owner of the pro~1ty. or my employees with wages as their sole compensation. will do the \\'Ork and the stnJti un:: is no!
<br />int ended or offered for sale (Scc.7044. Business and Pro fessions Code: The C'ontractor·s License Law docs not apply to m1 owner of
<br />the propcity who builds or improves thereon , and who docs such wo rk himself or herself or thmugh his or her own cmplo)ccs.
<br />provided lhfll such imp rovemenls are not intended or offered for sak:. IL however. the building or impro,·cmcnt is sold within one year
<br />of completion. the Owner Builder will have the burden of proving th at he or she did no! build or improve the pmpe,1 y for the puqx,se of
<br />sale).
<br />_I. as owner of the propeit y. am exclusively conlract ing with licensed contractors to co nstmcl the project (Sec. 7044 . Bus iness
<br />and Pmfcssion Cude: The Contractor's Li ce nse Law dot:s not apply to an ow ner of proper1 y who bu ilds or impro ves thereon.
<br />a nd who co ntracts for suc h projects w ith a Coutrn<.:tor(s) licensed pursuant to the Cuntra<.:tor's License L:1w).
<br />_1 am c.,cmpt under Section ________ . B. & P.C. fo r this reason.
<br />Date: __________ Owner:. _______________________ _
<br />WOl!KEl!S' COM PENSATION
<br />D ECLARATION
<br />I hereby affi rm under penalty of pe1jmy one of the fo llowin g dec laratio ns :
<br />_I have and will main1a in a Cert ifica te of Co nsent to Self-In sure for workers' co mpens.it icm. as provided for by Section 3 iOO of the
<br />La bor Code. for the perfo rm ance o f t he work for wh ich th e pcnnit is iss ued.
<br />Tran sf armers ~ .......__....., _I have aml will maintain workers' compensat io n insur,mcc. as requi red by Section 3700 oft he Labor Colic. for t he pcrfonnancc of
<br />'lJ1cb,.~v ~~ 17 '7-h.,u co \ {)rV\ h l \ 'l \ l l M-11 t;(Jo rJ ;··'"· work ro:;•hich this;r;-i~ iss,rl. My r ork:s' con~tion insnrancecr~~li~~n~~crare:
<br />Sub-Panels , '---\ Cnrric,____2-e\l\ ~l (Vl ~\A _u. U!.. r
<br />t-A-:-i:-r-=c-o-n-,-di-tio_n_e_r_s -----f-----+-----+-------------'d PolicyNnmber: \2. Wee? 1/( ~q'7 r E>pircs_l_L 0\3 2_
<br />t--------------------,-,-------+-------1-------------------lf,, Roof Top Equipment _I cc11ify that in the pe rformance of the wo rk for whi ch this perm it is issued, I shall not employ any pei-son in an)' manner
<br />so as to become su4icc1 to 1hc workers' compensation laws of California. a11 d agree th at if I should become subject to the F actorv Wired unit wo rkers' rompcnsation provisions of Section 3700 o r the Labor Code. I shall. fo11hw ith comply with those provisions ..
<br />Walls (Conduit)
<br />WARN ING: f a ilure to secure workers' compensation coverage is unlawful. and shall subjcc l an employer to l1iminal pc:naltics and Walls (Rouah) ci vil lines up lo one hun dred lh ousand dollars ($100,000). i n adll il iu n to the cost orcompcnsati o11 . danmgcs as prodded for the
<br />( S~tion 3076 o fthf Labor C~,c, intcresl and attomcy·s fees. £,,
<br />t-cc-=--e1-:-111n_,1Q.,_S---'c'-H_a_rd_&_S_o_ff_i\_R_o_u_,_,___gh-+------+----I------------IV'.~tc, t 21 os-1 \ 6 Ai>i>licant, A.,,/ c.__ -
<br />e11ngs T-Bar Rough, ~· 1 1 u r 'ENSE1"·=n "f'{IR
<br />M t R I ., ' I A l.A,,, Cf ll ) DEC LARATIOI\ I e e r e ease \ °\ [ 7 / 'r '-1( 7\ / J I hereby ar!irm un der penalty of pc1jury that I mn licensed under provision of~pter 9 (commencing with Section 7000) ofDivision 3
<br />or th e Business and Professio ns Code. and my license is in fu ll force and effec l.
<br />Rouqh , f _•"ctcensc('llas~ ~o'~ \\ ~--,_ L. ''"~'"""~ C \ 0
<br />t-S=e:-::--r::-::v-:-ic_e _M_e_te_r _____ --l,l'--,1-,,--/i-,-/_+-+.----,,-,-i---1------------11/ ~ -~ ~ -i -l ~ Conlractor: A-I OW} t 1-e C:J~ t., ,! (_ /K
<br />FINAL 'O/Zo//'-1-1,l'\-G'b ~-..... N_o_t_e_s_,_R_e_m_a-rk_s_,-E-tc-. ____ __...,....;.;.,._.-;, _ __. ...... ..,... ___ ..._ ______________ ---1 coNsTR u cT10N LENDING AGENcv
<br />I hereby affirm miller penalty of pc1ju1y lh al there is a co11st ntctio n lending agency fo r the pt.'1·fonmmce of the work r~lf' wh ich this permit is
<br />t;/,fl1 /Mo J✓ f tl,Tvt fu~ H//1.J,t..../J 'rft/Ct:.-0 -l--i h~ :;~~~/~~~;.,~97_.c_;"_·c_.J. _____________ _
<br />),tiJ/r I
<br />Lcnder'sAcldrL.-ss: _________________________ _
<br />APPLICANT D ECL ARATION
<br />I htTeby unirm under penalt y of perjury one of 1he follow ing declar,11 ions:
<br />Demoliti on Permits-Asbc..-stos Not ific at io n Federal Regu lations (Title 40, Pai16)
<br />_Requ ired Letter o f Notification
<br />_I ccr1ifythat the federal regu lntions l'Cgarding asbestns removal are not ~pplic able to thi s project.
<br />_I Ct.'111fy that I have real.I this app\1i~·at1011 and st at hm the .1bovc 111fo111m11on 1s concc:1 I agree 10 comply \\ 1th all C ity and County
<br />01dmanc es and State La,,s relat ing to bu1l cons uct1011 . and her eby ~hon ze reprcsc111at1\CS of I Ills City and County to enler upon 1he
<br />above mentioned ptopc1t y for mspecl1ot urp s --"'!! ......____. ) I
<br />t----------------------------------------------------\.-l/4p1,licant or Agen t Sign1>lnrc • ( ~ -IJ,llc \ 2 0 S I{,
<br />/ Pcnnilccn:1mc(print), L 'ct. I 1' t'\ '--1'-1 0 ~ 0 1 a VJ I
<br />\.J I
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