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ELECTRICAL-INSPECTOR RECORD APPROVALS DATE !D/SIG COMMENTS OWNER BUILDER DELCARATION I hcrcby affirrn undcr pen{lty of pcrjury that I m exempt fDm thc Contrcto$' Liccnsc kw for thc following rcarn (Scc.7031.5, Busincss and Profcssion Codc): Any City or County which rcquircs r fqmit to construcl, aher, improvc. dcmlish or rcpair any slructure, prior to ils issumc, ds rcquircs thc spplic{nl for such pcrmit to filc a signcd stalcmnt that hc or she is liccnsd pursuant to Ihc Fovisions of thc Contracror's Licenrcd taw (Chaptcr 9. Commrcing with Sation 7fi)0 of Division 3 of the Busircss snd PrclbssionsCode)orthatheorshciscxcmptthcrcfrcmondthcbasisforthcallcgcdcxcmption. AnyviolationofsslionT03l.5bysny applicant for a permit subjsts ihc applicant lo a civil penalty of not mrc than fivc hundrcd dollus ($50O), _1. as owner of thc propcrty, or my employccs with wagcs as thcir solc compcnsation. will do thc work and thc structurc is not interrdcd or offcred for sah (Sec.7O44, Business and Profcssions Codc: Thc Contraclor's Licensc law docs not apply to an owncr of thc pnrpcrty who builds or improvcs thcrcnn, and who docs such work himsclf or hcrsclf or through his or her own employces. providcd that such improvcnrnts arc not intcndcd or offed for s:rlc. If. howevcr. thc buihing or improvcnrnt is sold within onc )ear of comphtion, the Owner Buildcr will havc thc burdcn of proving thal he or she dkl not build or improve thc proprty for the purposc of sale). _1. as owncr of thc propcrty. am cxclusivcly contracting with liccnsed contraclors to construct thc projcct (Scc. 7W. Busincss and Profcsskrn Codc: Thc Contractor's License Law docs not apply to an owner of proF,crty who builds or improves thercon. and who contracts for such projccts with a Contractor(s) liccnsed pursuant to thc Contractor's Licensc taw). _l anr excmpt undcr B. & P.C. for this rcason. Owner: WORKTRS' COMPENSATION DECLARATTON I hereby affirnr under pcnalty of prjury one of thc following declarations: _l have and will maintain a Certifrcatc of Consent to Sclf-lnsurc for workers' compensation. as provided for by Section 3700 of the [:bor Codc, for thc pcrformance of thc work for which thc grermit is issucd. _l havc and will maintain workers' comlrcnsation insurance, as requircd by Scction 3700 of thc L:bor Code. for the performance of the work for which this permit is iszued. My workers' compcnsation insurance carrier and policy numbcr are: C.,f n Ia Policy e e-l) _l ccrtifythat in lhc pcrformancc of thc work for which this permit is issued. I shall not cmploysnypcrson in any lllsnncr so as to bccomc subjcct to the workcrs' compensation laws of California. and agrce thal if I should become subject to thc workers' compcnsation provisions of Section 3700 of the Latnr Codc, I shall, forthwith comply with those provisions.. WARNING: Failurc to wurc workcrs'compcnmtion svcrogc is unlowful. and shall subjcct an cmplolcr lo qiminrl Fmltics 8nd civil lines up to orc hundrcd thoussnd dollus (Sl0o,mo). in addilion to thc cos of comJrcn$tion, dmgcs &s providcd for thc Scction 3076 of thc l;rbor Codc, intcrcst and attorncy's fccs. l^/^,00 o, I hcrcby affrm under pcnalty of pcrjury that I am licensed under provision of Chapter 9 (comnrcncing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Liccnseclurr, . C - I O LicenscNumbcr: - q ? 6) g a o"rc, e ?- â‚¬-)l conrracror,* B{rt,oov 40.fr/l W t hcrcby afftrm undcr pcnalty of JE jury that thcrc is a onstruction lending ogcmy for the ]fTformncc of thc eork for which lhis lrrmit is issucd (Scc. 3097, Civ. C.). [.cndcr's Narnc: [.endcr's Addrcss: ASELICANLDEC|IAEAIION I Hy afm undr penalty of perjury ore of thc following dslsrations: Dcmlilion Pcrmits-Asbqtos Notification Fctcnl Rcgulstiotrs (Title 40. Pafi6) -Rc4uLed [rner of Notifrcarbn -l ccrlify that thc fedml rcgulations rcguding sbestos rcmval e mt applicsblc lo this prcj61. W-&*rrr r^l h8w rc8d this rpplicatbn lrd statc thal tlE aborc infornution is comt. I sgrc ro omply vith rll City and Counry odirares .rd State [{ws rchting to buiHing onstruciion, ard h@by authoriz rcprcsntatives of this City 8rd County to ents upon thc above rncntioncd propcrty for inspection 00 -g-r l Applicnnt or Agent Pernritee nanre rorinr):D(. WrLL OtOonwe tr h^.^. .1 Site-Work Underqround Pole Bases Light Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under Sl ab I Floor Bondinq I Groundinq / UFER 8--?s-vl lcn<f r{ z Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouqh Ceilinqs [-Bar Rouqh) lMeter Release 8-?x -?t DZ?(t',h- :^tt> (**eh Rouqh B-?-{- 2l D.t--t r.L Service N/eter Lt t-rV1 n .--..ll rb- FINAL I -?-{-? ^t rvG.n6* o*L Notes, Remarks, Etc. [Jr.r, nO n7 On{ tr Date:_ l q) q t 6 ' - t4-.1 I