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ELECTRICAL.I NSPECTOR RECORD COMMENTSAPPROVALSDATE!D/SIG a Site-Work Underground Pole Bases Lisht Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm I Darxpers Communications Cable Buildins Under SIab / Floor /1 2 Bondins I Groundinq / UFER l^-il'fr KIfrIIIIIJ/AY Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rough) Ceilinqs (Hard & Soffit Rouoh Ceilings (T-Bar Roush)t .t -^ -i llUrArtutrMeter Release l)'7.17 /6s Rough Service Meter A,,fr FINAL 7. lu'aUil lW'u<4wr Notes, Remarks, Etc..,I \ a- U OWNERBUILDERDELCARATION r I I hscby affm undo pcnahy of pojury rhar I m excmpr from rhc ConrmctoB' Licffi t w for thc fol0ir-o (Sc.7031.5 Buincs md Prof*ion Codc): Any City or County which rcquirs a pcmit lo construct, alta. improyl,&Jor rcpair my strudurc. Fior to irs isuucc, also rcquir6 thc applicant for such p.nnit to file a signcd ststmot rhat \!Cr=sea pwant to the povisioN of the Contractor's Licensed l:w (Chapt6 9, Commcncing uith Scction 7000 of Divl 3 trc Businss md Prcfesions Code) or that he or shc is exmpt th@from md thc b€sis for thc alleged cxmpion. Any viohf of !n 1031.5 by my applicant for a pennit subjets thc applicant to a civil pcnalty ofnot morc the five hundred dollas ($Slttrf |J _1. 6 oms of thc prcpeny, or my cmployc with wag6 s their $le compqrsation. rvill do thc wofk ed the structrc b not intqdcd or offqed for sle (Sc.7044. Busins md Profeiom Codq Thc Contractor's Licffc tiw do6 not apply to il oME of the pnrpxny who hrilds or imprcva thmn. and who doc such uort himsclf or hffielf or thrcugh his or ho own cmployrc, prcvidcd that such itnpiovmsts e not inlqded or olIqEd for salc. lf. howoq. the building or imprcvmmt is mH within one yw of complaion thc Orrne Buiktr will have thc hurdo of proving tha hc or shc dil mt huild or improvc thc propdy for thc puposof sle). __1, I oms of thc propsty, m cxclsively contracting rvith licmsed contracloB to snstrucl thc projecl (Ss. 7(N4, B6ins ild Proftsbn Codc: Th. Contmctor's Liccnse Law do6 nol apply to il owns ofprop€aly who builds or improvs lhqsn. and who contmcts for such projets wilh a Cont6cto(s) lic€oscd pu6wt to thc Contractor's Licme hw). -l m cxempt unds Sation---. B. & P.C. forthis rcen. Drl€: Owner: I hereby affirrn under penalty of perjury one -wORKERS'corltP DECLARATTON of the following declarations: -l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation. as gnovided for by Section 3700 of the Labor Code. for the performance of the rvork for which the permit is issued. _l have and rvill maintain workers' compensation insurance. as required by Section 3700 of the labor Code, for thc pa'formance of the work for which this permit is issuod. My workers' compensation insurance carrier and policy number are: Can'ier:- Policy Nurnber:_[ixpircs: __l certify that in the perforrnance of the work for rvhich this permit is issued. I shall not anploy any person in any manner so as to become subject to the rvorkers'compensation las's of California. and agrcre that if I should become subject to the workers' cornpensation provisions of Section 3700 of the Labor Code. I shall. forrhrvith cornply rvith those provisions.. WARNING: Failure to secure rvorkers' civil fines up to one hundred thousand Section .3076 of the l.abor Code. interest is unlas'ful. and shall subject an onployer to criminal peiralties and addition to the cost of compensation. darnages as provided for the oate: l?'l(- AO(4 I hereby affirm under penalty of pe{ury that anl 9 (cornrnencing rvith Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. l.icense Clu"r, 7 j 'lLro Number:D l)nte:ll-t1,2o01 P0 oQuuo&S - w5 I hereby affrrm under lsA aSency performance of the work for rvhich this pennit b issued (Sec. 3097. Civ. C.). Lendcr's Name: l,ender's Address: APPLICANT DECLARATTON I herdry affrm under penalty of perjury one of the following declarations: Dernolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Par16) -Required Letter of Notification -l certify that the federal regulations regarding asbestos removal are nol applicable to this project. that and state that the above infonnation is correct. I agree to comply with all City and County Latvs building construction. and hereby authorize representatives of this City and County to enter upon the atxlve property for prq)oses. Applicnnt Agent Permitee ro*qe#-@ E fle?(w Qc;ttd-_ r,r", l2ltt I n'olt l)n', nO n7