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ELECTR!CAL.INSPEGTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Poo!, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire AIarm I Dampers <br />Communications Cable <br />Building ,/ <br />Under SIab / Floor <br />Bonding I Grounding / UFER <br />Transformers <br />Torquing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment /)d?N . ulmh6 <br />Factory Wired Unit t \./ I <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soffit Rough <br />Ceilings (T-Bar Rough)\\t <br />Meter Release \\\ <br />Rough <br />Service Meter <br />FINAL \ <br />Notes, Remarks, Etc. <br />Owner-Builder <br />IherebvalfirmunderpenaltyofperjurythalIamexemptfornrtheContr.ctors l,icenseLswforthefollowingrason(ss.70l1.5Busincss <br />.nd Prof6sion Codc): Any City or Coun(y which rcquirB s pcrmit to constnrcl, sltcr. improve. dcmolish or rcpair any structurc. priDr to its <br />issuancc. also rcquircs thc applicant for such psmit to filc r signcd statcmcnt that hc or shc is liccNcd pumuant to thc provisions ofthc <br />Contr.clor's Licenscd tiw (Chaptcr 9. Conrnrencin8 with Setion 7000 ofDivision I ofthc Busincs and ProfessioN Codc) or thst hc or <br />shc is cxcmpl thcrcfton and thc basis for thc sllcgcd crcmption .Any violalion of s(rion 703 1.5 by iny rpplicanr for I pcnnit subjccts thc <br />applicant to a civil penelty ofnot morc thrn fivc hundrcd dollan ($500). <br />1.6 owncroflhcprcpcny,ormycmploycwilhwagcsasthcirsolccompcnsation.willdothesorkandlhcstructurcisnotintcndcd <br />or offcred for sale ( 5@.7044, Business .nd Professions Codei 'l he Contraclor's Liccnse Law does not spply to sn owne. ofthe prop.ny <br />who builds or improvo thcrcon. and who docs such work himrclfor hmclfor through his or hcr own cmployca. providcd thst such <br />improvcmcnls arc not intcndcd or offcrcd for sslc. If. howcvcr. thc building or improvcmcnt is sold within onc ycsr ofcomplelion. lhc <br />Owncr-Builds will havc thc burdcn ofprcving that hc or shc not build or improvc for thc purposc ofsalc). <br />contracting with licensed contractors lo conslruct the prqject ( Sec. 7044, tsusiness and'fhe Contractor's Law does nol apply to an owner of property who huilds or inrproves thereon. and who <br />conlracts such proiects with a licensed pursuant to tlre Contractor's l.rcense l^aw.). <br />under Section _.R. & P.C. for this reason. <br />Date: _ <br />I hereby affirrn of perjury one <br />Certificate of_l have and will to Self-lnsure for workers' compensation. as provided for by Section -1700 of the <br />I-abor Code. for the of the which the pernrit is issued. <br />.l have and will nraintain insurance. as required by Seclron -3700 of the l,ahor Code, for the performance of the <br />rnsurance carrier and policy nunrber are: <br />CL <br />Policy Number:-g <br />-Exp <br />ires, C <br />('l'his section need not for C)ne hundred dollars {$100} or less) <br />__l certify that <br />becanre subject r <br />ln of the rvork for rvhich this perrnit is issued. I shall not employ any person in any manner so a.s to <br />to workers' compensation laws of California. and agree that if I should beconre subject to the workers' <br />of Section 1700 of the l-abor Code. I <br />/o t{_Applicant <br />Failure to secure workers' conrpensation criminal penalties and civil <br />fines to one hundred thousand dollars ($100,000).in addition lo the cosl o[compensalion. darnages as provided for the Section 3076 of <br />Code. interest and attornev's [ees. <br />I hereby affrrm under penalty of perjury <br />the Business and Professions Code. and <br />LICENSED CON'TRACTORS DE(: LARATION <br />that I am licensed under provision of Chapter 9 (comnrencing rvith Section 7000) of l)ivision -1 of <br />rny license is in full frrr6s..a effect. <br />License class:--C--L q - <br />,,,", ll Jaq#_f <br />Number -LAC'kee 7 <br />I hereby affirm under penalty of perjury that there <br />issued (Sec. 3097. Civ. C.). <br />l-ender's Name: <br />agency the performance of the rvork for rvhich this permit is <br />l.ender's Address <br />APPLICANT'S DECLARAI'ION <br />l)ernolition Permits-Asbestos Notification Federal Regulations (Title 40. Part 6) <br />_ Required Irtterof Notification <br />I certify that the federal regulations regarding asbestos rernoval are not applicable to this proiect <br />that I have read this application and state that the above inforrnation is correct. I agree to cornply rvith all City and County <br />ordinanc6 and Slrtc tiws rclating to building comlruclion. and hrcby suthoriTc rcprGcntatirrs ofthir City and County to otcr upon thc <br />above mentioned property for <br />Applicant or agcrrt sig.: <br />Perrnittee narne ( print ): <br />purposes. <br />-Da,,, <br />ttlto f l{ <br />M :\W P5 1 \Perrnit- lrrspection <br />\ <br />I. as <br />Profession <br />work for <br />Carrier:_ <br />provisions. _/ <br />t