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APPROVALS Site-Work Underground Pole Bases LiQht 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-Pane ls Air Conditioners Roof Top Equipm e nt Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rough Ceilings (T-Bar Rouqh) Meter Relea se Rouqh Service Mete r FINAL Notes, Remarks , Etc. DATE ID/SIG. i l 7/Jo lr'.1- ELECTRICAL-INSPECTOR RECORD ' O WNER BUILDE R DELCARA TION ~7 COMMENTS I hereby .1ffirm under penalty of pc1jury that I am e.,empl from lhe C'ontractors· License Law fo r the following. re<lson (Sec,703 LS "'• Business and Professio n Code): J\ny City or Counly which requires a pennit 10 conslruct. ahcr. improve. demolish or repai r any slructure, prior to its issuance. also requires the ilpplicanl for such pen11i1 to file a signed stntcmcnt that he or she is licensed pursu:mt to the provisions of the Contractor's Licensed Law {Chapter 9 . Commencing wilh Sectio n 7000 of lJh·ision 3 o f the Blts im:ss and Pro fessions Code) or that he or slit: is c.,empt therefrom ,md the basis for the alleged cxcmp1icm. Any viol.it ion of Sect ion 703 1.5 by any applicant for a pcn1 1it subjec ts the applicant to a civi l penalty of not mo re than fi ve hundred do ll ars ($500). _I. ns owner oft he prope11y. or my emp loyees w ith w.iges n!i I heir sole compensat ion. wi ll do the wad, nm! the structure is not int ended or olTered for s.i le (Sec. 7044. Business and Professions Code: T he Contractor's License Law does not apply 10 an owner of the prope11y who builds or improves thereon. and who does such work himself or hersel f or through his or her 0\\-11 employet."S. prov ided that such imwm·cincnts are not intended or offered for sale. If. ho,,·e\·er. the building or imprnvemeni is sold wit hin one year of completion, tl1t: Owner Bui lder will have the burden of proving th at he or she did not build or impron: the pro1x.11Y for the purpose of sale). _I. as owner of the propei1y. a.i n exclusively c ontract ing with licensed contractors to C'o nstruct th e project (Sec , 70-M, B11si11ess and Profession Code: The Contrnctor's License Law docs not apply to an owner of prope11y who bui lds or improves thereo n. and who conlracts for such projec1s with n Contmctor(s) licensed pursuan1 10 the Con1rac1o r·s License Law). _l am exempt under Section ________ . B. & P .C. for this re11s011 . O.tle: __________ Owner:_W_O __ R_K_E_ll_S_' _C_O_~_IP-E-◄N_S_A_T_I_O_N ____________ _ llECLARATION I hereby affirm under penalt y of petjury one o f the fo llowing declarat ions: _1 have :md w ill m.iint.iin a Cc11 ilic;itc ofCcmsenl lo Self-Insure for workers· co 111 pe115ntion. as pro vided for by Section .''.t?OO o ft he Labor Code. for t he ptTfon nan cc of the work for which the pt..,,nit is issued. _1 have a nd w ill main1ain wo rkers' compcns.1t ion in surance. as rc<1uircd by Seel ion 3700 o f the Labor Code. for the pcrfonnnnce of the work for w hich this pcnnit i s issued . My work (.Ts · co mpensat ion insurance c.:UT icr am.I policy number arc: C m icr: ___________________________ _ Policy Numbcr: ______________________ Expires: __________ _ _1ce11if)1 1hat in 1he perfo rma nce of the work for wh ich thi s perm it is issued. I shall not emp loy any person in ,rny manner so as to become subjct:1 to the wor kers' compensation li1ws of Cali forn ia. mu.I agrcc.thm if I should become subject to the wo rkers· compensat io n pro visions of St-ct io n 3700 of1hc Labor Code, I slmll, fort hwith co mply with I hose provisions .. WARNING : r:ai lure to secure workers' compens.1tion co\'crage•~1s unlawful. an ,all subject an emp loyer to criminal }X"Tlalties and civil lines up to one hundred thousand do ll ars ($100.000). in a dit ion to t os~pc,~on. d.1111.igcs as prodded for the Secti on 3076 oftj e 7aoo/7 do/'ntcrcst an d attorncy·s fec.-s . er-/ ..,;9"".J 1 Date: /? f b/ , Ip) A pplica nt: ~ A"~/ I 1r ,--.-: '"'TR,\rTn....-V IIEC L ARATIO~ I hereby amrm under pen.i lly ofperjtiry lhrit I am licensed under pro\1is ion of Chapter 9 (commencing with Section 7000) of Division:; of 1he Business and Prorcssions Co de. and my license is in full force and effect . License Cl.1ss: ______________ Li cense Numbcr:A t:f ~£1{/_!3_ -;.,.. Date: / '( /t /_LC,. Contrnctor: X ·c_; £1 (/7;~// CONS'J"R ~C l"l~!lllz.ENCV I hereby a mn n under pen.illy of pe1jmy tlmt there is a const ruction lendi nb!, agency for the pcrfomi.111ce or the work for which 1his permi t is issued (Sec. 3097. Civ. C.). Lender"s Na me: _________________________ _ Lender's Address: _________________________ _ A PPLICANT DEC LARATION I hereby nllinn under penalty of perjury one of the follow in g dcc larat ions: Demolition Perm i1s-Asbcstos Notification Federal Regul at ions (Tit le 40. Part6) _Required LcttcrorNotification _I cci1ify th at the federal regulations regarding a5bestos removal ore uot applicable to this project. _I cci1ify that I have read thi s applicilli on and state that th e above infonnatipn is cmTcct. I 1.1grce to co m ply with all City and County ordmances an d State La\\S relattng lo bu tldtng c0nst111ct1 1n e1;_!)Y autho11ze 1cp1escntattvcs o fthts C1tv and Counly to enter upo n the abo,c mcnlloncd p,opc,1y rm mspc¥:J" p~s ff / _ / / Applkant or Agenl Sign,llurc V\_,. -1..J ~---,,,-(,,,/ l}nf c / ~c I It Pcrm ilce munc(print):_r~ &,/:"',. £. .