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APPROVALS Site-Work Underqround Pole Bases Lioht Standards Soas, Pool, Fountains Sians (monument) Life Safetv /Low Voltaae Fire Alarm / Damoers Communications Cable Buildina Under Slab I Floor Bondina / Groundino / UFER Transform e rs Toraueina Sub-Panel s Air Conditioners Roof Too Equipment Factory Wired Unit Walls (Conduit) Walls (Rouah) Ceilinas (Hard & Soffit Rouqh Ceilinas (T-Bar Rouqh) Meter Release Rouqh Service Meter FINAL Notes , Rem arks, Etc. DATE ID/SIG. ll ti lr:t JIJ1i///!J<J ' I ELECTRICAL-INSPECTOR RECORD COMMENTS O WNER IIUI Ll>ER l>ELCARATION I he1·eby .iflirm under penalty o f pc1jury !hat I mn exempt from the Contracto rs· License Law fo r the follow ing re ... son (Sec. 7031.5 Bus iness and Proression Code): Any Cily or Co un ty which requires a JX.11 nit to con st nu.:t. alter. improYe, demolish or repai~ ::o.,y s tru cture. prior to it s issuance. also requires the applicant fo r such permit 10 lile a signed statement that he or she is liccused pur s'i.ianl lo the pro,,isions of the Co utractor's Licenst::d Law (Chapter 9. Commen cing with Section 7000 of Divi5io11 3 of the Bu1:iness and Pro fessions Code) o r that he or she is exempt thercrrom and the basis for 1hc aHcgcd e.xemption . An y violation or Section 703 1.5 by nny applicnnt fo r a permi t subjc..-..:ts the app licant lo a civil pena lty of not more than fi ve hLmdred dollars ($500). .. _1. as owner or the prope11y, or my employees with wages as their sole compensat ion. will do the \vork and the structure is not intended o r ofli:rcd for sale (Sec. 7044. Business and Professions Code: The Contractor's Liccm;c L1w does not npply 10 nn owner or th e proper1y who builds or imprnvcs thcroon, ru 1d who docs such work hi msc:lr or hersel f or through his or her own e mployees. provided thnl such im pro\'emcnts are not intended or oJTcrcd for sale . If. however. the bu ilding or improvemenl is sold within one year or completion. the Owner Boil dt.T \\~II have lhc burden of prO\'ing lhat he or she did nol build or improve th e prope11y for the pi1rpose of ~,le). _I. as owneror the propeny. am exclusively con1rnc1 in~ with li censed ront ractors to constrnct the projccl (Sec. 70➔4. Business and PrurQision Code: The Contractor's License Law docs not app ly to an owner of prope11y who bu ilds or imp roves thereon. and who contracts fo r si1ch projects with a Contracto r(s) licensed pursuant to th e Co ntractor's Li cense Lmv). _I am e.xcmpt under Section ________ . B. & P.C. for 1his reason. Dale: __________ Owner:. _______________________ _ WORKllRS' CO~lrENSAT I ON UEC LARAT I ON I he re by affirm under pena lty of pc1jury o ne of the follow ing decbrntions: _1 have and will 111,1i111ain a Cc1tificate of Cons~nt lo Self-Insure for workers· compensation. as provided for by Sec::1io11 3700 of t he Labor Code. for the pt:.i·fon nancc oft he work for which the pennit is issued. ~rnve nnd will mainta in workers· compensation insurance. ns required by Section .HO O of t he Lnbor Code. for 1he per fo nnnnc:e of t he work for which this pc1111 i1 is issued . My workers' compensation insurance carrier and po licy number are: C;UTier,._~---~$,__(Pt""-''-'J-e_,'--""'-(P"--_vt....:._:_V1.,__~-'------------- Policy Number:_•----9++)_,_l_'J+-.,.(.,_·,..__.,.2-=---------Expi,·cs: _• __ [_c/_, L/_'S_,_-'-'--[_1,_ __ _I certify t hat in 1he performance of the work for wh ich this permit is issued. I shall not employ any person in any mmmcr so ns to become subject to the workers ' compensat ion laws of01lifo m ia. an d agree thol if I should become subject to the wo rk ers' co mpensatio n pro visions of Section 3700 of the Labor Code. I shal l. forc hwit h comp ly with those provisions .. WARN ING: Failure to secure workers· compensmi on coverage is unlawful. and shal l subject an emp loyer to afo1ina l pt..'nalt ics and civil fines up lo one hundred thousand doll ars ($1 00,000}, in addit io n to the cost of compensation. damages as prm·idcd for the Stclion 3076 of t he Labor Code, int erest and attorney's recs. Uatc: • \2.._ {... •I (o A p p lka nt:~ . ~ LI __E_N SlcD CONl RA C I O R l>EC L A RATION I hereby affirm under penalty orpc1jury 1ha1 I ,u n license..'<! under pro vision or Chapter 9 (commencing with Sec1ion 7000) of Di visi on 3 of the Business nnd Professions Code, and my li cense is in fu ll force and effect. License Cktss::_'•----'-~-----,--------Liccm;c N umber: , q ~ / / 2.-2-._ l)atc: __ ,. __ ii..12="'--''-"{,,:;__:,_J/'--"L'----Contrnctor .. .,."f-,,,__ __ ~=--~-___,g=-~c:=c:c._ __ ~ _______ _ CONSTRUCT ION L EN DING AGENCY I hereby affi rm un der penalty of pe1j ury thal there is n constmcl io n lending age ncy for the pcrfommncc oflhe work fo r \\'hich th is permit is issued (Sec. 3097, Civ. C.). Lender·s Name : _________________________ _ Lender's Address: _________________________ _ ArPLICA NT DECLARA TION I hereby affu,n under pe na ll y or pe1j ury one of th e fo llowing declarations: Demolit ion Permits-Asbest os Notification Federal Regulations (Title 40. Pa1t6) _Required Lt!l lerofNoti fication _I t.:ciiify t hat the federal regulations regarding asbestos remova l are not applicable to 1his project. ~ .✓.:crtiry that I hn\·c read this .ipplication and stale that tl1c above infonnat ion is correct. I agree to comply with all Cit y and County 1----------------------------------------------------~-I ordinances and State Laws relat ing lo building const111ct ion. and hereby .iuthorize represenlat ives of th is City and County lo enter upon tl1c above mentioned prope11y fo r inspc...-ction purposes. Applicant or Agent Signa111re: "'f-~~ Pcnnitcc nnmc (p rinl): )( 6'1 1'('\cr G!vc//-e.,.r-.