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ELECTRICAL.INSPECTOR R ECOR D APPROVALS DATE ID/SIG.COMMENTS Site-Work Underground Pole Bases Liqht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under Slab / Floor Bondinq I Groundinq I UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouoh) Ceilinqs (Hard & Soffit Rouqh Ceilings (T-Bar Rouqh) N/eter Release I t i Rough -0 1-1.\, ,APff Service Nleter FINAL lD -f -Lt r ' t' rlL Notes, Remarks, Etc. + I hcrcby aflirm undcr Fnalty of perjury that I om cxcmpt ftom lhc Contrelon' Licensc llu for the following rcarcn (Scc.7Q1l.5 Busincss and Profcssion Codc): Any City or County which rcquircs a Jrcrmit to snslruct, altcr, imprcvc, dcmlish or rcpair uy sEoclm, Fior to its issuancc, also rcquircs thc applicant for such Frmit to filc a signcd slalcnEnt that hc or shc Ls licensd pusanl to lhc prcvisions of $e Contr.ctor's Liccnsed hw (Chupter 9, Commcncing with Sction 7000 of Division 3 of thc Busiress and ProtbssionsCodc)orthathcorshciscxcmpttlscfrcmandthcbasisforthcallcgedcxcmption. Anyviolationofsstion?03l.5byany applicail for a frcmit subjets thc applicant to a civil pcnalty of nol mrc tho five hundrcd dollus ($500). _1. as owncr of the propcrty. or my cmployccs with wagcs as thcir solc cornpcnsation. will do the work and the structure is not intendcd or ofl'cred for sale (Scc.7044, Busincss and Professions Codc: T'hc Contractor's Liccnsc Law does not apply lo an owncr of thc pn)F,crty who builds or inrprovcs thcrcon. and who dcrcs such work hirnsclf or hersclf or through his or hcr own cmployccs, providcd that such improvcrcnts arc not intcndcd or olTcrcd for sah. If. howcvcr. the building or improvenrcnt is rcld within onc ycar of conrphtion. thc Owncr Buildcr will have thc burdcn of proving that hc or shc did not build or inprove the propcrty for thc purynse of salc). _1, as owncr of the propcrty, am cxclusively contracting with licenscd contractors lo construct thc project (Scc. 7(144', Busincss and hntbssion Codc: Thc Contractor's Liccnsc Law docs not apply to an owner of propcrty who builds or improves lhcreon, and who contracts lbr such projccts with a Contracto(s) licenscd pursuant to the Contractor's Liccnsc Law). -l am cxcmpt undcr Scction-. B. & P.C. for this rcason. Owner: W(IRKERS' COM PF'NS ATION DECLARATION I hcrcby affirm undcr pcnalty of pcrjury one of thc lbllowing declarations: _l havc and will rnaintain a Ccrtificate of Conscnt to Self-lnsure for workcrs'compcnsation, as providcd for by Seclion 3700 of thc [:bor Codc, for the perfornuncc of the work for which the grcrmit ls issucd. -l havc and will maintain workcrs' compcnsation insurance, as requircd by Section 3700 of thc labor Codc, for thc pcrformance of the work for which this pcrmit i.s issucd. My workcrs' compensation insurancc carricr and policy number are: o Policy 1D _l ccrtily that in thc pcrlbrnrancc of the work lor which this is issucd. I shall not cnrpkly any person in any manner so as to hcc<lrnc subject workers' c<llrtpcnsation to the workcrs' compcnsation and agrcc that if I should bccome subjcct thc provisions of Section 3700 of thc l,abor I shall. tbrthwith comply with those WARNING: Failurc lo sccurc wrlrkers' comlrcnsation ls and shall subjcct an employer penalties and civil fincs up to one hundrcd thousand dollars ($100.000),cost of comlrcnsation,as provided for thc Scction l.atxlr and attorncy's fecs. I hcrcby aflirm undcr pcnalty of pcrjury that I arn liccnscd under provision of Chapter 9 (comnrcncing with Scction of thc Busincss and Codc, and rny liccnsc is in full force and cffcct.I Licensc Nuurbcr: Dare: eJ'at'l .\f xr- ll- Ul CONSTRUCTION LENDING AGENCY I hercby altirm undcr pcnalty of pcrjury lhat thcrc is a construction lcnding agcncy for the pcrftrrmance of thc issued (Scc. 3097. Civ. C.). which this pcrmit is [.crrdcr's Narnc: lrndcr's Address: APPI ICANT DF'CI ARATION I trcrcby allinn undcr pcnalty of pcrjury onc of the lbllowing declarations: Dcnmlit ion Pcrmits-Asbcstos Notitlcat ion Rcgulations (Title 40, Part6) _Rcquircd lrtter of Notilication asbcstos rcmoval arc not applicablc this projcct. that thc abovc infornulion is I agrcc to City and County abovc mcntionctl propcrty for Applicant or Agent Pernrilec nunre lo and hcrcby authorizc oI lo cntcr uJxln lhc [f,n.r nO n7 On1tr t2 IDate:_