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ELECTRICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG . COMMENTS OWNElt IIUILDER DEIX /\lv\TION 1 hereby affir m under pe na lty of perj ury that I run exempt from th e Cont racl ors ' License Law for the fo llowing reason (Sec.7031.5 Site-Work Business and Profe.,;s ion Code): An y C it y nr Count y wh ich req uires a pcnnit to constrnc t. alter. im pro ve. demolish U l' rq}air any stru cture. prior to its is suance. also req uires the a pplicant for such pe rmi t 10 file a signed statement tl rnl he or she is licen:-;ed pursi1ant Underqround lo the pro \•is ions o f the Co ntractor's Licensed La w (Chapter 9. Comme ncin g with Section 7000 of Div isio n 3 of 1he IJusiness and Pole Bases Pro fes sions Code) or tha t he or she is c:<cmpt therefrom and th e bas is for the alleged exemp1io n. Any violati on of Sccli{)11 703 1.5 by any applic an t for a penn il subjec ts the applican t lo a civil penalt y o f not more th an fiv e hundred dollars ($;CO). Light Standards _I, as owner of the pro pe rty. or my employees with wages as thei r so le compensation. will do the work an d the st nicture is not Spas, Poo l, Fou nta ins int ended or o rrered for s.1lc (St.-c.7044, Business ,md Pro fessions Code: The Contra clor's Lic ense Law docs not app ly to an owner of the property who builds or imprO\'es thereo n. and who docs such work l1 imself or herself or thro ugh hi s or he r own employt::es. S igns (mon ument) prn vided thnt such improvements arc not intended or offered for sale. If. however, 1hc bu ildi ng or improvement is so ld with in one year o f complet io n. the O.vn er Builder will have the burden or prov ing that he or she did not build or im prove the propci1y for the purpose of ~ os owner of the prope11y. am exclusively contractin g with lic ensed cont ractor< to constn,ct th e project (Sec. 7044. Bus iuess Life Safety /Low V o ltage Fire A larm I Dampers and Pro fession Code: The Contractor 's License Law docs not apply to an owner o f property who builds or improves th ereon. and who contra cts for such projects wil h a Contractor(s) lit.:cnsed pursua..nl to the Contrn clor 's License Law). Commun ications Cable _, """'"" 'V j '" ef;t""''"-" -~-?<--Dnt e· b-~ O wner : .-'~ Building ",vol<KERS' CO~I PENSATION u u DECLARATION Under Slab / Fl oo r I hereby affirm und · pen alt y of perjury one o r the follow ing declarations: Bondinq /Grounding/ U FE R _I have and will ma intain a Certificate o f C011sc11t to Sel f-In sure for workers· co mpensalion, ns provided for by Section 3700 of the La bor Code, fo r the pcrfonn ancc o f the wo rk for which th e penn it is issued. T ransformers _I have .:ind will ma int.lin wo rkers' compensntion insurnm:c. as required by Section 3700 of the Labo r Code. for the perfonmmce of T orqueinq the work fo r which this pcnn il is issued . My workers ' compensat ion insurance can-icr and policy num ber arc: Sub-Panels CaJTicr: Air Cond itioners ,{7') b -. / o ic y um er: l::.:p ires: ( W c,iiry that in the performance of t he work for whi ch this permit is issued, I shall not employ auy person in any ma nuer Roof T op Equ ipme nt Factory Wired Unit so as to beco me subj ect to the workers' compensation laws of Cali forn ia. and ngree I hat if I should become subject to th e workers' compensation provisions ofSt.!C tion 3700 oflh e Laber Code. I shall. fmt hwith co mply with I hose provis ions .. Wall s (Conduit) WARNING: Fai lure to secure workers' compensa tion coverage is unlawful. and shall subject an employer to criminal penalties and Wa ll s (Rouq h ) ci vil fines up to one hu ndred thousc1ncl dollars ($100.000). in .tddi tion lo lhe cosl o f co mpensrll ion. damages a s provided for the Cei lings (Hard & Soffit Rouq h Section 307z7;La~h dc. iutcrcst and attorney's rees. .,:;:? } _ // Cei lings (T -Bar Rouq h ) Dntc: f , /P_ 1/,h A ppli cant: 'i:£&r~~ .,,,,e.-( l --~ LI CEN C N RACTQR ,, Meter Re lease ~ DECLARATION I hereby c1 nirm undc penalt y of perjury that I am li censed umlcr provision of Chapter 9 (commencing with Section 7000) of Di\'ision 3 ;; of the Bus iness and Professions Code. and my license is in full fo rce and effect. Rouqh ~f-11'--l 7 X,\L C71~ Lic cusc Class: Service Mete r u V Li1:ensc Num bt.-r: ~ FINAL ~~._,,,, 'A~ ~ Date: Cont rnct ur : Notes, Remarks, Etc. V '-...I C O NSTRUCTION I.EN DI NG AGENCY 1 hereby a nirm under pe na lt y o r pe1jurythat th ere is a constnu:tion lending agency for the pt.Tformance of the work fo r whkh this p<.TJnit is issued (Sec. 3097, Civ. C.). Lender's Na me: Le nder's Address: A PPLICANT 1>~:CLAll ATION I hereby affinn und er penalty o f pcljury one of th e fo llowing declarnlions · Demolition Pcrmits-Asbt s tos Notification federal Regu lat ions (Titl e 40. P.u16) _Re<1uired Lcttcr ofNotificntion , ·::;-1 Ct.i-t ify that the federal regulati ons regarding asbestos re moval are not appli cable to this project. -,9 vi{ ctTtify that 1 have read this .1ppli cation and state that the above info rmat ion is correct. I agree to comply with nil Cit y and Count y ordinauccs and State Laws rclnt;ug to bu ild' c structio,,, a"d hereby author~is City and County to cntcT upo n the above ment io ned prn pcn y for in~'?,~ . < ~ ,I/, Applicant or Agent Signatu re:_ <-;!; p$?-L>ate ; '-~ ,.✓ 1/ b I k /),'f)y// _/-' c._ P~~ e~ I I I Permitcc name (1,rit1t): ~ a,. .. , ('IQ t\7 ·;rd k {./ u