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ELECTRICAL.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS I hdcby arrm undq pcnaifif pcd,o ?"* ,"X1:$#H'.tL'f"1i[l#t1l*" ** ror the rotlowing r"*n (se.7o-tt.s <br />Businas and Prof*sion Codc): Any City or County which require a po'rnil to construct, alt6, improvq demolish or rcpeir any <br />structue. prior to its issumcc ds requirB thc applicml for such pemit to file a signcd statqnEt that hc or shc i5 liccEcd pmuant <br />to the provisiom of thc Contnctor's l-icosed l:rv (Chapt6 9, Commocing wilh Sction 7000 of Division 3 of thc Bwins md <br />Prcfoions Code) or that h€ or shc is cxmpt thqcfrom ild thc besis for thc allegcd cxmpion. Any violation of S61ion 7031.5 by any <br />applicantforapcmitsubjctsthc applicanttoacivilp@altyofnotmorcthilfivchundreddollm(t500). <br />syt. 6 omr of thc poJrry. or my cmplolm with wagc c their rcle compffilion. willdo thcwrk ud the struclw is nol <br />intoded or ofIqcd for $lc (Se.7044. Busire ud Profcssioro Codq Thc Contraclor's Liccm lrw do6 not apply to m oms of <br />thcprotEty whohitdsorimprccthoatratdwhodo6Mhrcrthirelforhffilforthrcughhisorhromoployc. <br />providcd that such imFovqruils rc rct intadod or offscd for slc. lf. horvws. thc building or imptovmt is mH within onc )a <br />ofcomplaion thc Owno BuiH6 will harc thc hldo ofprcving thd he or strc did not build or imFove thc prcpdy for thc purpos of <br />sle). <br />_1. as owner of the property. am exclusively contracting rvith licensed contraclors lo construct the project (Sec. 7044. Business <br />and Proftssion Code: The Contractor's License Law does not apply to an orvner of property who builds or improves therctrn. <br />and who contracts for such projeds wilh a Contracto(s) licensed pursuant to the Contractor's License larv). <br />-l <br />am exempt under Section u /this reason. <br />Date:_L1 9- 7a <br />I hereby affirm un}ff pWalty of perjury one of the following declarations: <br />*fu*llE:X;:fli,T:;:It;"ffi1[i"::iHl"J"L,;:;lers'compensation' <br />as providcd rorbvSection3T00orthe <br />_l have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the performance of <br />thc work for which this permit is issued. My workers' compensation insurance carrier and policy number are: <br />c*iot / <br />Policv Nurnber:Expires: <br />r- l.cerlify that in the performance of the rvork for rvhich this permit is issued. I shall not anploy any person in any manner <br />so as to become subject to the rvorkcrs'compensation larvs of California. and agree that if I should become subject to lhe <br />work€rs' compensation provisions of Section 3700 of the Labor Code. I shall. forthu'ith cornply rvith those provisions.. <br />WARNING: Failure to secure workers' compensation coverage <br />civil fines up to one hundred thousand dollars ($1001000). in <br />Section -j076 of the Labor Code. interest and attorneyrs fees. <br />is unlarv[ul. and shall subject an empkryer to crirninal pcnalties and <br />'compensation. darnages as provided for theadditioncost of <br />\ <br />I hereby affirm under penalty of perjury that I arn licenserJ under provision of Chapto' 9 (cornmencing with Section 7000) of Division 3 <br />of the Business and Professions Code. and my license is in full force and effect. <br />l,iccrrsc ('lass: <br />l)nte: <br />License Number: <br />Contractor: <br />W <br />I hcby aflirm undo pc! alty of pgjury that thqe b I con$rucrion lmding agmcy for thc pqfot1mcc of thc work for which this pqmit is <br />issucd (Se. 3097. Civ. C.). <br />Lender's Name: _ <br />Lender's Address: <br />APPI ICANT DECLARATION <br />I hrlrby affirm under penalty of perjury one of the folbwing declarations: <br />Dcmolition Permits-Asbestos Notificatioo Federal Regulations (Title 40. Part6) <br />-Required <br />lrtter of Notification <br />_l certify that the federal regulations regarding asbcstos removal are nol applicable lo this project. <br />and state that u'ith all City and County <br />and County to exter upon the <br />abovc rnentioned propcfly for <br />Applicant or Agent <br />l'crrn ilee rrnme ( prinl ):€Dr-4aPo <br />Ihlc:-13-bb <br />Site-Work <br />Underqround <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor , <br />Bonding I Grounding / UFER 4VUqP (W tfur) <br />Transformers I I ur \- <br />Torqueincl ..,4. <br />Sub-Panels zltTl ge',W lw) <br />Air Conditioners I I ur ,-/ <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Roush) <br />Ceilings (Hard & Soffit Roush <br />Ceilinqs (T-Bar Rouqh) <br />[\4eter Release <br />Rough <br />Service Meter I <br />FINAL 4zll"a w ,tfu ) <br />N Rema Etc. <br />()^', nQ n'7 '>n4f."