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ELECTRICAL.! NSPEGTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS <br />Site-Work <br />Underground <br />Pole Bases <br />Lisht Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Ala rm I Dampers <br />Communications Cable <br />Buildins <br />Under SIab / Floor <br />Bondinq I Groundinq / UFER <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinss (T-Bar Roush) <br />Meter Release <br />Rough <br />Service Meter l, I f - t) <br />FINAL nt(0t(u /)/r?rw <br />Notes, Remarks, Etc.I <br />I hmby affm undo pcnalty of pcjury that I fln cxcmpt fiom thc Comractoa' Licw law for the following r€er (&c.70]1.5 <br />Busines md Profsion Codc): Any City or County which requirs a pannit to corutruct, alte, improve. <hnofh odlir uf <br />structuq pdor to its isumcc. also rcquim the applicat for such pcmit to filc a signcd stamot thd hc or slrciAcrocd-lNant <br />to the provisioro of rh€ Contractor's Liccnsed taw (Chaptq 9. Commcncing with Setion ?000 of Division 3 ?i thc Bsin;s ild <br />Prcf6sionsCodc)orthatheorshciscxmptih@fromodthcbasisforthcallcgc{cxemption. AnyviolationofsElionT03l.5bymy <br />applicant for a pcrmit subjets thc applicet to a civil pcmlty ofnot morc thil five hundrcd dotlus ($500). <br />_1, c oms of the prcpcny. or my employc with wag6 6 their slc compqsation. will do th€ rc* ild thc stnrclrc is not <br />int@ded or offdcd for slc (Se.7044. Bsirs od Prcfsioc Codc: The Contractor's Licce kw doq trot spply to e omq of <br />th€ prcpqry who tuilds or tnprovs th@n. ed who do6 such w* hiroclf or hemlf or thrcugh his or ha om mployc. <br />providcd that such imprcvmts se mt intsded or offqcd for salc, If. how6. thc building or imprcwt is wld within onc )ar <br />of compliiorl the Ovn6 Buiklq will havc thc hqlen of prcvirg tha he or shc did mt build or imtrorc thc popa'ty for thc purposc of <br />slc). <br />_1. r ownc of thc prop<rty, m cxclusively contrac{ing with licenscd contrrctoF lo oNlrucl thc projel (56. 7044. BBins <br />ud Profsion Code: Thc Cootractor's Licmsc Law do6 not apply to m owns of prcp€rty who builds or improvs thq@n, <br />and who contncis for such prcjets wilh a ContBcto(s) licoscd pm@t to thc Contmc{or's Licw trw). <br />I <br />-l <br />am exempt under B. & P.C, for this reiuon. <br />WORKERS' CONT PENSATION <br />DECLAR,{TION <br />I hereby aflirm under penalty of pojury one of the following dcclarations: <br />_l have and will maintain a Certificate of Consent to Self-lnsure for workers' cornpensation, as provided for by Section 3700 of the <br />Labor Code. for the performance of the work for which the perrnit is issued. <br />_l have and <br />the work for <br />rvill 3700 of the labor Code, for the performancc of <br />are:and policy number <br />Policy <br />.(,ccrti$ that in the perforrnance of the work for which this perrnit is issued. I shall not employ any person in any manncr <br />to become subject to the workers' cornpensation laws of Califonria. and agree that if I should become subject to the <br />workos' cornpensation provisions of Section -i700 of the labor Code. I shall. forrhwith comply with those provisions.. <br />WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subject an and <br />civil lines up to one hundred thousand dollars 100,000), in cost of the <br />Section 3076 of the interest and fees. <br />I hereby affirm under penalty of pcrjury that I am p,rovision of Chapter 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Code. and rny liccnse is in full force and effect. <br />o <br />CONSTRUCTION LENDING AGENCY <br />I h@by affm undd pcnalty of pqjury thst thqc is I omtruc{ion l@ding ag@cy for thc pqfomilc€ of thc rcrk for which this pqmh b <br />issucd (56. 3097. Civ. C.). <br />Lcnder's Name: <br />Lender's Address: <br />APPLICANT DECLARATTON <br />I hereby alfum under penalty of perjury one of thc following declarations: <br />Demolition Perrnits-Asbcstos Notification Federal Regulations (Title 40, Part6) <br />-Required <br />Letter of Notification <br />_l certify that the federal regulations regarding asbcstos rernoval are not applicable to this project. <br />-I <br />ccrlify that have read this application and state that the above with all City and County <br />and County to enter u5r,on theordinanccsandStateLawsrelating <br />above mentioned property for <br />Applicnnt or Agent <br />Permitee name <br />to construction.and \ <br />Rev. 08-07-2015 <br />Section <br />Exoires: <br />to <br />,L <br />infonnation is conect. I <br />,,,", /o/z/' -