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APPROVALS Site-Work Underground Pole Bases Light Standards Spas, Pool , Fountains Sign s (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Building Under Slab / Floor Bonding / Grounding / UFER Transform e rs Torqueing Sub-Pa ne ls Air Conditioners Ro of Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rough) Ceiling s (Hard & Soffit Rough Ce iling s (T-Bar Rough) Meter Re lease Rough Service Mete r FINAL Notes , Remarks, Etc. ( '/ DATE ID/SIG. n ~ ELECTRICAL-INSPECTOR RECORD COMMENTS O W NEll llU I U)EI! U ELCA llATION I hereby a rfirm under penalt y or perjury tha1 I am exempt from the Contrn ctors· License Law for the folllming n::;1su11 (Scc.703 1.5 Business a nd Profession Code): Any City or Coun ty which requin:s a pcnnit to constm cl, alter. impro\'c, demolish or repair any structure. prior to it s issu ance. a lso requ ires th e npplicant for s uch pcnnil to fi le a s igned stalcm ent that he or she i<; licensed purs~<lllt to the provis ions of the Contractor's Licensed Law (Chap1er 9. Commencing with Section 7000 o f Division 3 of tht: Business and Professions C'od c} or that he or she is exi:mpt therefrom and the basis for the alk gctl exem p tion . A ny viulat iu 11 of Sect ion 70 3 1.5 by any applicant for a pcnnit subjects the applicant to a c ivil penalty of not more than five hundred doll ar·s ($500). _I. as own er o f the pn,pcr1y. or m y employees with wa ges as t heir sole co mpensation. will do the work and the strucllu-e lS not intended o r olTered for sale (Scc.7044, Business and Professions Code: The C'ontractor·s License Law does not .ipply to ;m tl\rner of th e prnpe11y who builds or improvt'S thereon. and who docs such \\'Ork him self or Ju:rs clf or through his or h er own cmp!O)ces. provided th at su ch improvem ents arc not inten ded or offcn .. 'tl for sale. If. howc\'cr. the building or im pro\'ement is sold with in one year o f complclion. the Owner Builder will h:we the burder1 of proving 1hn1 he or she did not build or impro\'e the propei1y for the purpose of s.1le). _I. nsowncr nf1he propet1y. am exclusively cont racti ng with licensed co nlrnclors In conslmct the project (Sec. 70-M. Business a nd Profession Code: The Contractor·s L icense Law does nol apply to an owner of pro perty who builds or impro\·es thereon. and who contracts for such proj ects with a Conlrnctor(s) licensed pu rsuant to the Contractor·s License Law ). _I am exempt under Section, ________ , 0 . & P.C. for th is reason. Date: __________ Owncr:-c==-======-==,------------- WO l!K El!S ' COMP ENSA T IO N D EC LARA TIO N I hereby anirm under penalty of pc1j ury o ne of the following declaratio ns: _I have and will mai111 ain a Ce11 ificate of Consent 10 Self-Insure for workers· compe nsat ion. as pro vill ed for by Seel ion 3700 o f the Labor Co de. fo r the perform ance of t he work for which the pc1111it is issued. _I h ave and will 111ain1ai n workers· co mpensation insurance. as req uired by Section 3700 of the Labor Catie. fur t he p.;,.•rfornwncc of th e work for whic h th is pcnnit is issued. My wo rh·rs· compensation insurance carTier nnd policy number a rc: Ca,,-ier:_-_T,_~r_._·_-_$_-f--_~_+-< _____________ _ Policy Number:/ g v,J ~ @. 0 3 b < e </ ExpirCs: --'~2--_ _,/~•_,_(~· -7~-- _I cc11 ify that in the performance of the wo rk for wh ich th is perm it is issued, I sha ll not employ any person in any manner so ns to become suqjcct to the workers' compensation laws of Cali forn ia . nml agree tlmt if I should become s ul~iect to the workers' compensation provisio ns of Secti on 3700 o f the Labor Code, I s hall. fo rthwith comply with those provisions .. WARN ING: Failure to secu re worke rs' com pensa tion coverage is u n la wful. hnd s hall su bject an employer to e1iminal pcnahtcS a nd c ivil fines up to o ne hundred thousand doll ars ($1 00,000 ). in add itio n to 1hc cosl o f com pensal ion. dmnng.es ns provided for 1he Section 307~ ofth~f abor Co<y, interest and nttomcy·s fees. ../"1 -4"" Untc: ) '2-. { I q f I k, App li c-1/ // , ----/ • "-» l 7tic~;N"".U CONT RACTOR l -.__ 1>EC LAllATIO N I hereby affirm under penaltyofpe1j ury th at I am licensed under proYisio n of Chapter 9 (commencing with Section 7000) of Division 3 of the Business .ind Professions Code. and m y li cense is in full force mid efT~c t. License Class:_,.·/ ...----,1.-0 _______ . -,4.lj ccusc mbcr : ~ '3 9' I) 7 7 Unl c :_.,__{ /J-"=-l{l-'l'--j} t lo Con1rn~-~ ~=::::'.:-4::::::::_~_sC..,_'_;c~,,__ __ I I /r: CONSTl!UCTIO N LENDING AGENCY I hereby anirm untlcr penalty o f pcrjur)' that there is a construction lend ing agency fo r the pt.,·fonna11ce oftht;: work for which this permit is issued (Sec . 3097. Civ. C.). Lender's Name: _________________________ _ Lendcr·s 1\ddress: _________________________ _ APPLICANT DE C LARATION I hcn: .. -by affi11 11 under penalty o f perjury o ne of t he fo llowing dcclarat ions: Dcmo li1ion Pcrmits•Asbestos Notification Federal Regulations (T itle 40. Part6 ) _Requi.-cd Let1crofNotiricn1K)11 _I certify th at the federn l regulat ions regarding asbestos rem o\·a l a re no t npplicable to this projec L _I cc11ify !hat I have read t his applic ation and slate thnt th e above inform .it ion is correct. I .igrcc to comply \\'ith all City nnd Cou nty ordmance!; ;md SI ale Lm1,s 1ek1tmg t~n:bu1ld11 nst ru ct10n. and he 1eby authorize representatives ofth1s C1tv and C mml )' to enter upon the abov~ 111ent1011cd prop~1ty for ''."F''°" ,rpo cs ~ ---~ / / • f' A p pllcan l or Ag cn t S ,g n nllu .f ~ /4.. Un tc ( 2..~( 'j ~ Pc r111 itcc11a 111e (pri11t): ~} /""",e_.. $~ L::ct: