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ELECTRICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS Site-Work Underground Pole Bases Light Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Buildinq Under SIab / Floor Bondins I Groundinq I UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilings (Hard & Soffit Rouqh Ceilings (T-Bar Rough) Meter Release r\ Rough !arl+.n- fwPldP 6-1-7) Service N/eter >,ID[\tFINAL)-lCr"A Etc. t Art$ \r. cx&)( I Co,v NA/ OWNER BUILDER DELCARATION I hercby affrm undcr pcmlty of prjury that I m cxcmpt from thc ContractoE' Liccns kw for the folk wing rcasn (56.7031.5 Busincss and Prcfcssion Codc): Any City or County which rcquircs a prmit to construct, altq, improvc, dcrclish or rcpir any structre, prbr to its issuance. also rcquires thc applicanl for such pcmit to fik a signed statcmnt thsr hc or slE is liccnsd pu6ltnt to thc prcvisions of thc Contrrctor's Liccnscd law (Chaptcr 9, Comcrcing with Section 7000 of Division 3 of thc Busircss and ProfcssionsCodc)orthathcorshciscxcrptthcrcfrcmandthcb&sisforthcallcgcdcxemption. AnyviolationofscctionT03l.5byany 8pplicant for a pcrmit subjsts thc applicant to e civil pcnalty of not rrcrc than fivc hundrcd dollus ($500). _1, as owncr of thc propcrty. or my crnployccs with wagcs as thcir solc compcnsation, willdo thc work and thc structurc is not intcndcd or ofl'cred for salc (Scc.7044. Busincss and Professions Code: The Contractor's Liccnsc [-aw does nol apply to an owncr of thc propcrty who builds or improvcs thcrcon, and who docs such work hirnsclf or hcrsclf or through his or hcr own cmployccs. providcd that such irnprovcrncnls are n<lt intcndcd or offcrcd for srh. If. howcvcr. thc building or irnprovcnrnt is sold within one ycar of complction, lhe Owner Builder will havc thc burdcn of proving that hc or shc did not build or improve thc propcrty for thc purJrcsc of sah). _1, as owncr of thc propcrty, am cxclusively contracting with liccnsed contractors lo construct thc proict (Scc. 7W, Busincss and Prrolbssion Code: Thc Contractor's Licensc Law docs not apply lo an owncr of propcrty who builds or improvcs thercon. and who contracts for such projects with a Contractor(s) liccnsed pursuant to the Contractor's License L:w). -l am exempt under Section-. B. & P.C. for this rcason. It... ^.Owner: WORKETIS' COMPENS,\TION DECLARATION I hereby affirm undcr penalty of pcrjury onc of the following dcclarations: _l havc ard will maintain a Certificatc of Consent to Self-lnsurc for workers' compcnsation, as provided for by Section 3700 of the Labor Code. for thc ;rcrformancc of the work for which thc 1rcrmit is issucd. -l havc and will maintain workcrs' compcnsation insurance, as requircd by Scction 3700 of thc labor Codc, for thc pcrformancc of thc work tbr which this pcrrnit is issucd. My workers' compensation insurancc carricr and policy number are: Carrier: Policy Numbcr: Expircs: _l ccrtify that in thc performancc of thc work for which this pcrnrit is issucd, I shall not cnrploy any pcrson in any manncr so as to bccornc subict to thc workcrs' com;rcnsation laws of California. and agrce that if I should bccomc subject to thc workcrs' compensation provisions of Scction 3700 of thc Labor Code, I shall. fbrthwith comply with thosc provisions.. WARNING: ftrilurc to sccure workcrs'conrpcnsation covcragc is unlawful, and shall subject an cnrploycr to criminal pcnaltics and civil fincs up to onc hundrcd thousand Section 3076 of thc Labor Code. intcrest dollars ($100.000).lo thc cost of com;rcnsation. damages as providcd for the and attorncy's fccs. r5 I hcrcby affirm undcr pcnalty of perjury that I am liccnsctl under 9 (commencing with Scction 7000) of Division 3 of thc Busincss and Profcssions Codc. and my liccnsc is in full forcc and cffcct. Licensc o,r", 0S/O6/ 2/ I hereby affirrn undcr penalty of pcrjury that thcrc issued (Scc. 3097, Civ. C.). a aScncy the pcrfornuncc <lf thc work for which this prrnit is lrnder's Namc: Lcnder's Address: APPLICANT DECLARATION I hcrcby affrrn undcr pcnalty of Jrcrjury one of the following declarations: Dcrrrolition Pcrmits-Asbestos Notification Federal Rcgulations (Title 40. Part6) -Rcquircd l,ettcr of Notification _l certify that the federal rcgulations rcgarding asbcstos rcmoval arc not applicable to this project. _l certify that I have rcad this application and state that the above information is correct. I agrcr to comply with all City and County ordinanccs and State l;rws rclating to construction. and hcrcby authorizc reprcscntativcs of this Cily and County to cntcr upon thc abovc mcntioncd propcrty for Applicant or Agent Pernrilee noma I)atc:a6/o6/2/ AQ on{ tr YJYIrLIA) iP(\ (printl, // '4