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ELECTRICAL.I NSPECTOR RECORD <br />[."] ,.r r <br />APPROVALS DATE ID/SIG.COMMENTS <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltase <br />Fire Alarm I Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bondinq I Groundinq / UFER <br />Transformers <br />Torqueinq <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 Rouqh) <br />Meter Release <br />tl ,l,l-w>aRough?t1 'lo <br />Service Meter Ir <br />FINAL )Dft rf lt.l *tr/ <br />Notes, Remarks, Etc.\I <br />OWN I.]R BU I l,DER DI]LCA RAI'ION <br />thC l(rIlr'\\'lllt tCil.St\tl ^il'itttpltrrc. tlclttt,lislt ()t' rcpiir' ,uE <br />that lrc t,r shc is liccnsetl p'rrsrrartl <br />I hereby affrrm under penalty of pcrjury that I arn exempt from the Contractors' License Law for <br />Business and Profession Code): Any City or County rvhich requires a permit to construct. alter, <br />structure. prior to its issuance. also requires the applicant for such pcrmit to file a signed statement <br />to thc p@visioN of thc Conuetor's Licnscd Lrw (Chapt6 9, Com@cing with Sction 7000 of Division 3 of thc Busir* ud <br />pmfBions Codc) or th8t hc or shc is exmpt th@from ed thc basis for thc allegcd exmption. Any violation of Setion 7031.5 by any <br />applicet for a pcrmit subjets the applicet to I civil pcmlty of not morc the fivc hundrcd dollm ($500). <br />_1. c oma of thc p.opcrty, or my cmplo)6 with wag6 s thcir slc compcnsation, will do the wt dd thc stnEtw is not <br />intqrded or offscd foi slc (Sc.?044. B6itre md Prcfeiom C.ode Thc Contrrctor's Licre Law doc not 4Ply to e oMs of <br />thc propsty who builds or improrc thsoil @d who dG such wrk hirelf or hmclf or thrcugh his or ha om oployc. <br />proridcd that such impro@ts rc rct intqrdcd or offscd for slc. l[ howq, thc building or impovmt is mH within one ]qr <br />of onplaion thc olurc Buildq wi[ harc thc tuda of poving tha hc or shc did rct build or itrprorc thc propqry for the txrpos of <br />slc). <br />_1. s owns of thc propqty. m qcluively contracting with licqEcd contractoB to coNlruct thc projal (Se. 7044, BGinN <br />ard profssbnCodc:ThcContractor'sLicoscLawdoenotapplyioeownoofprcpcnywhobuildsorimprov6th6@n. <br />md who contracts for such prcjets with I Crntncto(s) licoscd purmt lo thc Contraclor's LicN taw). <br />-l <br />m cxmpt unda Sction-, B. & P.C. for this roon. <br />( )u rter' <br />WORKER.S' COM PENSA'IION <br />DECLAITATION <br />I hereby afftrm under penalty of perjury onc of the following declarations: <br />_t have and will maintain a Certificate of Consent to Self-lnsure for workers' contpensation, as provided for by Soction 3700 of the <br />labor Code, for the pcrformance of the work for which the pcrmit is issued. <br />_l have and will maintain workers' compensation insurance. as required by Section 3700 of the l-abor Code. for the performance of <br />the work for which this permit is issuod. My workers' compensation insurance carrier and policy number are: <br />L \i369,-\\ lrr uf,)r)L F\gE il.tS. (Js <br />Policy I G3S\bol ol /or ( <br />"4,2--e <br />_l certi$l that in the perfonnance of the work for which this perrnit is issued, I shall not ernploy any person in any manner <br />so its to become subject to the workers' cornpensation larvs of California. and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code. I shall. forthrvith comply with those provisions.. <br />WARNING: Failure lo secure workers' compensation coverage is unlawful. and shall subject an onployer to criminal panalties and <br />civil fines up to one hundred thousand dollars ($l in addition to the cost of compensation. damages as provided for the <br />Section 3076 of the tabor Code. interest and fees. <br />\./'--q 5 r1 <br />I hereby aflirm under penalty of perjury that I arn licensed under 9 (cornmencing with Section 7000) of Division 3 <br />of the Busincss and Professions Code. and rny liccnse is in full force and effcct. <br />\312--t\q,License .-\>Nurnbcr: <br />CONSTRUCTION LENDING AGI]NCY <br />I hwby affirm unds penalty of pcrjury that th6e is a constBction lmding agency for thc pafomuce of the work for which this permit is <br />Civ. C.). <br />Lender's Address: <br />APPI ICANT DF'CI ^RATION <br />I herdry affrm under penalty of perjury one of the following declarations: <br />Demolition Permits-Asbestos Notification Federal Regulations (Title 40. PaI16) <br />-Required <br />Letter of Notilication <br />-l <br />ceni$ that the fueral regulations regarding asbestos removalare not applicable to this project. <br />_l cerrify that I have read this application and state that the above infonnation is corect. I agrce to cornply with all City and County <br />representatives of this City and County to enter upon theordinances and State Laws relating to construclion. and hereby authorize <br />above nrentioned property for <br />Applicnnt or Agent <br />I'erlrrilce nanrc Pe J <br />.9 tq, <br />Dft (V) <br />I)ate:_ <br />or,., *{ | lf/ l 1,