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ELECTRICAL.!NSPECTOR RECORD <br />f)^'no n7,n-tq <br />APPROVALS DATE ID/SIG COMMENTS <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm I Dampers <br />Commrrnications Cable <br />Buildins <br />Under Slab / Floor I ^l -&. <br />Bonding I Grounding / UFER l'7w0 tfr<Y) n .ql 6 / <br />Transformers I il <br />Torqueing <br />Sub-Panels <br />Air Conditioners I <br />Roof Top Equipment t ulLq Dt\nf.n .b+x7 <br />Factory Wired Unit I <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinss (Hard & Soffit Rouqh <br />Ceilings (T-Bar Roush)I <br />Meter Release I t h-i hkrn,-#ry %:2)4rl <br />Rough <br />Service Meter I <br />FINAL I ,-flh D|}..rfl,4'#ffi <br />Notes, Remarks, Etc.,I t'I <br />OWNER BUILDER DELCARATION <br />I hachy affum unda pcnalty of perjury thar I m cxcmpt ftom thc ContEctoB' Lictre kw for thc following rcen (Se.7031.5 <br />Businss atrd Profoion Code): Any City or County which rcquiro a pamit to construct, alts. improvq dcmolbh or rcpair ily <br />structuq prior to its isuucc. also requirG thc applicot for such pcnnit to file a signcd st8t@ot lhat hc or slE b licosd p|Nmt <br />to thc provisioN of thc Contractor's Licmscd law (Chap6 9, Commocing with Secrion 7000 of Division 3 of thc Busins ad <br />Pmfcssions Codc) or that hc or shc is cxmpt th6c{rom ud thc b€sis for thc allcgcd crmption. Any violation of Scclion 7031.5 by any <br />applicant forapcmit subjatsthc applicail to acivilp€naltyofnot morcthe fivchundrcddollas($500). <br />t <br />-1. <br />as owner of the property. or my ernployees rvith rvages as their sole compensation. rvilldo the work and the structure is not <br />intended or offered for sale (Sec.70t4. Business and Professions Code: 'l'he Contractor's License Law does not apply to an orvner of <br />the property who builds or ilnproves thermn. and who does such rvort hirnself or herself or through his or her own ernployees. <br />provided that such irnprovements are not intended or offeted for sale. If. howwer. the building or improvanent is sold rvithin one year ri <br />of cornplaion. the Owner Builder will have the burden of proving tha he or she did not build or imp,rove the propory for the purpose of <br />sale). <br />-1. <br />as owner of the property. am exclusively contracting with licensed conlractors to construct the project (Sec. 7044. Business <br />and Pmftssion Code: 'l'he Contractor's License Larv does not apply to an owner of property u,ho builds or improves theretrn. <br />and who contracts for such projeas with a Contracto(s) licenscd pursuant to the Contractor's License Law). <br />-larnexemptunderSection-.B.&P.C.forthisreason. <br />Date:Owner:-- <br />WORKER.S' COI}I PENSATION <br />DECLARATTON <br />I hereby affinn under penalty of perjury one of the following declarations: <br />-l <br />have and rvill rnaintain a Certifrcate of Consent to Self-lnsure for rvorkers' compensation. as provided for by Section 1700 of the <br />Labor Code. for the perfonnance of the work for which the pennit is issued. <br />-_l have and will rnaintain rvorkers' compensation insurance. as required by Section 3700 of the Labor Code. for the perftrnnance of <br />the rvork for which this pennit is issued. My workers' comp€nsation insurance carrier and policy number are:A I /CL <br />Policy <br />-Expires:_l certify that in the performance of the rvork for which this permit is issued. I shall not employ any person in any manner <br />so as to become subject to the work€rs'compensation lau's 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 thosc provisions.. <br />WARNING: Failure to secure workers' compensation is unlawful. and shall subject an onployer to oiminal penalties and <br />civil frnes up to one hundred thousand dollars addition to the cost of compensation, darnages for the <br />Section 3076 Labor (--ode. interest fc'es. <br />I <br />I hereby affrrm under penalty of perjury that I arn licensed 9 (comrnencing with Section 7000) of Division 3 <br />of the Business and Professions Code. and my license is in full force and effect. <br />License c'(D Nurntrer: <br />ct? 37 fQ <br />I hereby aflinn under penalty of perjury that <br />issued (Sec. -3097. Civ. C.). <br />is lcnding agency for the performance of the rvork for rvhich this perrnit is <br />Lender's Name:- <br />Lender's Address: <br />APPLICANT DECLARATION <br />I her*,y affirm under pcnalty of perjury one of the following declarations: <br />Demolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) <br />-Required <br />Letter of Notification <br />with all City and County <br />and County to enter upon the <br />Permitee f ntcL Vct <br />Z e <br />I <br />? ?/lq <br />,,r", t l/L\ /q Dqn;e t r,ur|h\