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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby affirm umlcr pcnolty of perjury lhot I mt cxcmpl fiom lhc Conlraclos' Liccnrc hw for lhc following rca*rn (Scc.7o.ll 5 <br />Busincss ond Profcssion Cttc): Any City or County which rcquircs r fErmit lo conslrucl. allcr, improlc. demlish or rcIEir any <br />structurc. prior to its issuarcc. also rcquircs the applicanl for such [Er[il lo lilc { signed statcnEnt thol he or shc is licensd pu]suf,nl <br />to thc provisions of thc Contr[ctor's Liccnscd Ltrw (Chnptcr 9. Conrnrcncing with Sslion 70U) of Division 3 of the Busincss and <br />prdcsskrr Codc ) or lhat hc or shc is cxempt thcrcfrom and thc h{sis for rhe alhgcd cxcmption. Any violution of Scclhn TO3 l 5 by rny <br />{pplicanl for a pcrmil suhjccls lhc applicant to a civil pcmlly of nol rmrc lhan fivc hundrci dollurs ($5il)) <br />_1, us owncr of thc proFrty. or my cmplolres wilh wtrgcs ils thcil solc com{rcnsolfun. willdo thc work and thc slnrc{urc is nol <br />intcrxlcd orolTercdfilJb(Sa.Z044.BusircssandProfcssionsCodc:ThcContractor'sLiccnrclnwd@snotlpplytornowncrof <br />lhc pmFf,y who builds or inpmvcs thcGrn. ond who d(Es skh w)rk hinrsclf or hcr$lf or lhmugh his or hcr own cmployccs. <br />pmriacO rhat such imprcrcmnts m mt iilcndcd or otfcrcd for slc. lf. howcwr. lhc building or itr{rrcrcmnl is mld within orrc pu <br />;fcorr{rhtiotr. lhc Owrcr Buildcr will harc thc hurdcn ofpmving that hc or she did not huild or hnprcvc thc Imlf,rty for thc purlns of <br />slc). <br />_1. as owncr of the propeily. ilm exclusivclyconlracling with liccnsd conlructom lo onslruct lhc pmFct (Scc. 7(X4. Bu$incss <br />srxl ftof6shnCodc:ThcContrrctor'sLiccnscLawdocsnolapplyrranownerofpropcrlywhohuildsorimprovcsthcrcon. <br />and who contruclsforsuchprojcctswithaConlncto(s)licensdpursuantlothcCbnlractor'sLiccnscbw). <br />-l <br />arn cxcrrrpt under B. & P.('. lirr this rcits()tl. <br />l)ale:_( )w'ner: _ <br />WORKERS' CONTPENS {TION <br />DECLARATION <br />I hcreby affirm under pcnahy of pcrjury one of thc following declaralions: <br />_l havc and will maintain a Ccrtificatc of Consent to Sclf-lnsure for workcrs' compensalion. as provided for by Section 3700 of thc <br />Labor Codc. for the performancc of lhe work for which thc pcrrnit is issucd. <br />_l have and will maintflin workcrs'conlpcnsation insurance. as rcquired by Section 3700 of the l-,abor Code. for ltrc Jrcrformance of <br />thc work for which this permit is issued. My workers' conrlrcnsation insurance carrier and ;nlicy numbcr are: <br />Policy Nurnbcr: ExPires: <br />_l ccrtily lhat ilt thc pcrkrrnmnce of thc work lirr which this pcrrnit is issued. I shall not entployany pcrson in any manncr <br />so us lo bc'cgr.rrc suhjcct ro thc workcrs'contpcnsation laws of Calitbrnia. ancl agrcc thal if I should trccotltc subjcct lo thc <br />workers' colnpcnsalion provisions of Scction 37fi) of thc Lahrr Codc. I shall. lbrthwith cotnply with thosc provisions.. <br />WARNING: I;ailurc lo scurc workcrs' conrpcnsalioll covcritge <br />civil lincs rrp to ollc hundrcd lhousand doll:rrs ($luJ'000)' ilt <br />is unltu'l\rl. antl shall subjccl an crnploycr to critninal Jrcnaltics and <br />cornpcrtsation. damagcs as provided lor thclo lhe cost ol' <br />Scction .l0T(r of thc Labor Codc. intcrest and atlorncy's <br />/to /tn Appricanr:- <br />l'ccs. <br />I ):rtt : <br />q <br />I hcrchy al'tlrnt uttdcr pcnalty tll'pcrjury thal I aln liccnscd undcr of Chaptcr 9 (contttrcncing with Scctiott 7(ru0) of Division -l <br />of thc Busirrcss arrd Profcssiorrs Cotlc. antl rtty liccltsc is in full fttrcc attd cl't'cct. <br />l-iccrtsc Nurrrbcr: <br />aDate: I /I / tq contracro.' * <br />CONSTRUCTION LENDTNG AGENCY <br />I hcrcby aflirrn undcr Jrcn{ltyofpcrjury thrt lhcrc is d conslruclion hnding ugcrcy for thc pcrfornEnce ofthc work for which this Jrcrnrit is <br />issucd (Scc. 3097. Civ. C.). <br />Lcnder's Namc: <br />I-cnder's Address: <br />APPLICANT NECLARATION <br />I lrcrchy allirrrr under pcnalty of pcrjury onc of thc ltrllowing declaralions: <br />Dcnrolit ion Pcrrnits-Asbestos Notification Fcderal Rcgulations ('l'it lc 40. Part6) <br />-Rcquircd <br />lrttcr of Notification <br />_l certily that thc l'ctlcral rcgulatiorrs rcgarding asbcslos rctloval ilrc tx)t applicuble to this projcct. <br />_l ccrtily that I havc rcad this application antl stalc that thc abovc itttorlttalion is corrccl. I agrcc to conrPlY <br />' rcprescnlativcs oI this City <br />with all City and Counly <br />and Counly lo cnler ulnn thcordinances and Statc Laws rclating to building cortslruct ion. atxl hcrchy :tul horizc <br />above rncntioned proprty lbr inspction <br />Allplicanl or Agertl Signnlure: <br />Pennilce nnnre (;lrinl l:1fu (nll;"<t - 'vrxBr<tn| Ml;q-&- <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bondinq I Groundinq / UFER <br />Transformers <br />Torqueincr <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinss (Hard & Soffit Rouqh <br />Ceilinqs (T-Bar Rouqh) <br />N/eter Release <br />Rouqh <br />Service lVleter <br />FINAL //-r-at tL t,r NUo, Ztl <br />Notes, Remarks, Etc. <br />C)r.', nO fl? 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