|
ELEGTRI CAL.I NSPEGTOR RECORD
<br />APPROVALS DATE ID/SIG COMMENTS Owna-Builda Dcclmtion
<br />I hcby rfilrm mdcr paalty of pcrjury thrt I mcxmpt fm thc CmtrctoB' Liccolc Lrw for thc following rcaon (16.7031.5 BuinBr
<br />ud hofaim Codc): Any City 6 County which rtquirtr r pcnnit to cffitnrcq dtd, improvc, dmolish u rcpair uy rtrucrurc, lris to itt
<br />imarcc, rbo rcquim dE eplic]lt for tuch pcrmit ro filc a rfncd nrt66t thrt hc or rhc is licmcd punuut to Oc prcvirimr of thc '
<br />Cqrmctq'r Licarcd bw (Chryta 9, Comr€nciry wlth Sccdon ?oo0 of Dvi:im 3 of thc Burincas md Profasim Co&) tr thst hc tr
<br />shc i! qallPt thcrcfrom uld thc blrir fa thc .[c8cd flcmptim .Any violetion of Scctim 7031.5 by my applicsnt for r permir rubjeB thc !lpplicrtlt to r civil paalty of ool mG thm livc hmdrcd dolls (S500).
<br />_1, a MGr of thc prcpcrty, d my mployd with wr86 I thcir rolc cmpmation, witl do th€ sork md thc ttrucluc ir not intmdcd
<br />or ofrfrd fa ldc ( Se.7044, Euins md Prcfsiw Codc: Thc Conindtr'r Limc Lsw dc nor apply to m owna of thc propcny
<br />who buil& or imFovct thcr6o, md who dH ruch work himclf or hcllclf a throu8h hi! c ha own cmploye, providcd thar ruch
<br />imprcvmmt! e nd intmded d ofr@d fot mlc. If, howaa, thc building or imprcvmcnt i: rold within onc ycu of complction, thc
<br />Oma-Buildd will havc thc burdcn of prwiag that hc u rhc not build tr imprcve for thc purposc of salc).
<br />-I,
<br />a owncr of thc propcrty, m cxcluivcly cmEetitrg with liccrocd cmlt&toE to construd thc projccr ( Scc. ?044, Bsinst sd
<br />Prcfaim Codc Thc Cfitrrcltr'! Licdc Lrw dm not ipply to m ownc of prcpcrty who buildr q improvd rhficon , ed who
<br />cmtrrcB fd ruch projccts with r Cmrrto(r) Iicmscd pmmt to rhc Contractu'r Licensc Law.).
<br />_I un cxempt under Section & P.C. for this rcason.
<br />Date: Owner:
<br />WORKERS COMPENSATION NECLARATION
<br />I hereby affirm und6 penalty of pajury onc of the following dcclaruions:
<br />_IhrvcudwillmalntrinrCatificucofCoamttoSGlf-InsEfdworkm'cmpcolrtion,u povi&dfcbySerioi3Tooofrhc
<br />Irbor Codc, fc thc pcrfrme of thc wqt fm which thc pqmit lr isucd.
<br />-lhrvcmdwillminuinwctm'mpanrdionin$rrncc,u
<br />rcquircdbySetio3T00ofthcLaborCodr,fortheperfommccJfrhc
<br />wck for which thir psrnit ir isucd. My wchen' cmpca$tion iromcr crnia ud policy numbcr rc:
<br />Policy
<br />(This scction need not bc completcd the pctmit is for One hundred dollars ($tOO; or lcss)
<br />6rthatinthcpcrformanccoftheworkforwhichthispcrmitisirsuc4tshallnotemployanypersoninanymannersoasto
<br />becamc tubjcct to the workcrs 'compensation l&ws of Californig and agrec that if I should bccome subject to the workers'
<br />3700 of thc Labor Code, I fonhwith with
<br />WARNING: Failure to secure workers' compcnsation
<br />fines up to onc hun&ed thourand dollars ($100,000),in addition to
<br />Oc kbor Codc, intcrat md rnomcy'r fa.
<br />LICENSED CONTRACTORS DECLANATION
<br />I hacby efiirm udr pcndty of pajury thu I m licarcd mda prcvitim of Chspts 9 (commcing wirh sccrion ?000) of Division 3 of
<br />drc Buina md Prcfetion! Codc, sd my lic6c ir in full fmc od cffcr.
<br />License
<br />Date:
<br />I hereby aftirm under pcnalty of perjury that there
<br />issued (Sec. 3097, Civ. C.).
<br />Lender's Name:
<br />a agency the performancc of the work for which this permit is
<br />Lendcr's Address:
<br />APPLICAI{T'S DECLARATION
<br />Dcrnolition Permie-Asbestos Notification Federal Regulations (Title 40, Pan 6)
<br />_ Required Lener of Notificstion
<br />-I
<br />certify that the fedcral reSulations regarding asbestos removal are not applicable to this project,-s" €
<br />:{"^frthat I have rcad this applicetion and state that the abovc information is correct. I agree to comply
<br />ordinances and State Laws to building construction, and hereby authorize rcpr$entativcs of this City
<br />with all City and Counry
<br />and county to enter upon the
<br />above mentioned propcrty
<br />or
<br />(print):J.*, A&..a,,^ ,+. Nol4 a
<br />b\b
<br />Site-Work
<br />Underground /^
<br />Pole Bases 7b?,b5 \A-43a )
<br />Light Standards MsA-r +$,n ,eo)
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm I Darnpers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torquing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rough
<br />Ceilings (T-Bar Rough)
<br />Meter Release
<br />Rough
<br />Service Meter
<br />FINAL 1q)4(0,. (t,,c-ilild,
<br />Notes, Remarks, Etc.
<br />(
<br />,rr^ ,ftr 3S
<br />JJs6
<br />/ ,(
<br />c l,
<br />,F
<br />J
<br />i{zq6s'-*
|