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ELECTRICAL-I NSPECTOR RECORD r.1 ,.,, i'i(J 11"/..}fi.1 ,i APPROVALS DATE ID/SIG.COMMENTS Site-Work Underground Pole Bases Light Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm I Dampers Communications Cable Building Under SIab / Floor I rl /) Bonding I Grounding / UFER t l"\w hlLnnr:.il4-l Transformers I I I Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rough) Ceilings (Hard & Soffit Roush 1Qgalrngs (T-Bar Rough)I 1 / Meter Release Dfhn0u .v51 \\\I Rough Service Meter rt .l -.ril F!NAL DIh,nt AzXU ' Notes, Remarks, Etc.'1 -\tlT ) \ ,/ I hoeby affirm undr poalty of pcrjury that I atr crempt frorn the ContractoF' Licf,s law for thc follorving rcrrn (5(.7031.5 Businqs md Profcssion Code): Any City or County Nhich rcquire a;rmit to omtrucl. ah6. improvq dmolilf, or rcpoir doy structurc. prior to its i$uocc. also rcquirB the applicot for such pef,nit to filc a signed starmqt that hc or shc b licosed puyarr to the provisioN of thc Contractor's Liccnsed Larv (Chapts 9. Commqcing with Setion 7000 of Division 3 of rhe Businm and PrcfcssionsCode)orthatheorsheisexemptthqefromandthebsisfortheallcgederonpion. AnyviolationofSstionTO-ll.5byany applicantforapmitsubjctsthe applicanttoacivilp€naltyofnotmorethanlivehundrcddolltrs($500). --1. as o\\'ner of the proFrrty. or my employees rvith s'ages as their sole compensation. lvilldo the u,ork and the structu'e is not intended or offered for salc (Sec.7044. Business and Professions ('ode: The Contractor's l-icense Larv does not apply to an orvner of the propory who builds or improves thereon. and rvho does such u'ork hirnself or herself or through his or her ow'n employees. provided that such improvonents are not intended or offered for sale. lf. hos'ever. the building or irnprol'ement is sold rvithin one )tzr of complaion. the Olvner Builder u'ill have the burden of proving that he or she did not build or improve the fnoperty for the purposc of sale). -1. as owner of the propoty. aln exclusively conlracting u'ith licensed contractors to constntct the pro.ject 1Sec. 7044. Business and Profcssion Code: 'I'he Contraclor's License Las' does not apply to an o$'ner of proper-ty rvho builds or improves thereon. and s'ho contracts for such projects rvith a Contracto4s) licensed pursuant to the Contractor's License Las'). I alrr crcrnllt urrclcr Scctiorr l)ntc: _. B. & l'.('. for this reason. Orr ner: WORKERS' (:ONT PENSAI'ION DECLARATION I hereby affirrn under penalty of pojury one of the follorving declarations: -l have and s'ill mainlain a Cerrificate of Consenl to Self-lnsure for s'orkers' compensation. as provided for by Section 3700 of the Labor Code. for the perfonnance of the rvork for rvhich the perrnit is issued. I have and the work for rvill maintain rvorkers' compensation insurance. as required by Section .1700 of the l-abor Code. for the perfonnance of u'hich this permit is issued. My u'orkers' compensation insurance carrier and policy number are: nrnLvWnn ZWLU^x-;t\ lr ltqPolicyru,rr,,tr"r'WL I qo quotb ---l cerrify that in the performance of the rvork for rvhich this pennit is issued. I shall not ernploy any person in any manner so as lo beconte sub.iect to the rvorkers'cornpensation lau,s of California, and agree that if I should become subject to the \\'orkers' cotnpensation provisions oISection 3700 of the Labor Code. I shall. forrhrvith comply u'ith those provisions.. WARNING: Failure to secure rvorkers' compensation coveragc is unlas'firl. and shall subject an to ancl civil fines up to one hundred thousand dollars ($100.000). in addition to the cost the Section 1076 of the l,atnr Code. interest and attorney's ??\4 I hereby alTirm under penalty of perjury that I arn licensed 'hapter 9 (cornmencing rvith Section 7000) of Division.l - Conrrac,( LicenseNu,,k ,lrnzaSb 7\ V tvtutt 3o\'zr? CONSTRUCTION LENDING AGENCY I hcrcby alfim undc pcnalty of pcrjury thar thqe is a consruction klding agocy for thc pcrfomacc of thc work for which this p6mit b issucd (SB. 3097, Civ. C.). Lods's Namc: _ Lender's Address: _ APPLICANT DECLARATION I hoeby affinn under penalty of perjury one of the follorving declarations: Demolition Permits-Asbestos Notification Federal Regulations ('title 40. Parr6) -Required Letter of Notification cerlify that the federal regulations regarding astrstos rernovalare not applicable to this project. colify that I have read this application and state that the above infcrrmation is correct. I agree to cornply rvith all City and County antl State ,it \\'s relating representatives of this (-ity ancl County c'nler ur)n tnenlioncd properly [or or Agent Signature:l)above nRnre (print): building A kro v^-Ao"t.,-\[7 Itt e1 tlre of the Business and Professions Code. and my liccnse is in full force and effect. r)are: T lzl CtolL Io