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ELECTRICAL.I NSPECTOR RECOR D <br />D,-.., nA n7 On1tr <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby slfirm undcr lrcmlty of pcrjury that I en cxempt frcm thc Contructo6' Licens law for the following rcarcn (SN.7031.5 <br />Busincss and Profcssion Code): Any City or Counly which rcquircs a lEmit lo construcl. altcr, improvc. dcmlish or rcpair any <br />structurc, prior to its issumc, alm rcquircs thc applicanl for such lEmit to filc a sigred statcrent lhat hc or slrc is liccnsd pu$ant <br />to lhc pmvisions of lhc Contractor's Liccnsd kw (Chaptcr 9. Commercing with Setion 7(X[ of Division 3 of lh€ Busiress rnd <br />PrclbssionsCode)orthathcorsheiscxcmptthcrctiomandthcbasisforthcallcgcdcxcmption. AnyviolalionofsrctionTO3l.5byany <br />spplicotrt for a pcrmit subjccts thc applicant to a civil penalty of not more than fivc hundrcd dollus ($500). <br />_1. as owner of thc property, or my cmployccs with wages as thcir sole comlrcnsalion. willdo thc work and thc structurc is nol <br />intcndccl or offcrcd for sale (Scc.70{4, Busincss and hofessions Code: The Contraclor's Licensc Law does nol apply to an owncr of <br />thc proprty who builds or improvcs tlrcrcon, and wh<l does such work hirnsclf or hcrsclf or through his or hcr own entployees. <br />providcd that such improverncnts arc not furtendcd oroflbred for sah. lf, howcvcr. lhc building or irnprovcrncnt is sold within onc ycar <br />of conrphtion. thc Owncr Buildcr will havc ttrc burden of proving that hc or shc did not build or irnprovc thc propcrty for the purynsc of <br />sh). <br />_1. as owner of thc propcrty, am cxclusivcly contracting with liccnscd contractors to construct thc project (Scc. 7U4. Busittcss <br />and Protbssion Codc: The Contractor's Licensc Law docs not apply to an owncr of propcrty who builds or improves thercon. <br />and who contracts for such projccts with a Contractor(s) liccnscd pursuant to lhc Contractor's Liccnsc Law). <br />-IamcxemptundcrScction-,B.&P,C.forthisrcason. <br />J}r'la.l lrunor <br />W()RKERS' COM PENSATION <br />DECI ARATION <br />I hcreby alfirnr undcr pcnalty of Jrcrjury onc of thc following dcclarations: <br />havc and will nraintain a Ccrt iljcatc of Conscnt to Sclf'-lnsurc for workcrs' conrpcnsation. as providcd for by Section 3700 of thc <br />I-:bor Crile. for the Jrerformance of thc work flor which thc lrcrmit Ls issucd. <br />havc and will nraintain workcrs'compensation insurancc. as rcquircd by Scction 3700 of thc [-abor Codc. for thc perfonnancc of <br />which this pcrmit is issucd. My workcrs' compensation insurance carricr and plicy numbcr arc:thc work Ibr fu* <br />Policy Nurrrbcr: %ooo n6/3 2//Expires: <br />_l ccrtify that in thc pcrforrnancc of thc work flor which this pcrnrit is issucd. I shall not cnrploy anyperson in any manner <br />so as to bccomc subjcct to thc workcrs'conrpensation laws of Califbrnia. and agrec that if I should bccome subjcct to the <br />workcrs' compcnsation provisions of Scction 3700 of the L:tnr Codc, I shall. forthwith cornply with those provisions.. <br />WARNING: Failurc to sccure workcrs' compcnsation coveragc is unlawful. and shall subjcct an cmploycr lo criminal pcnalties and <br />civil fincs up to onc hundred lhousand dollars ($100,0001, in addition to thc cost of comfrcnsation, damagcs as providcd for the <br />Scclion 3076 of thc Latnr Code, intcrest and attonrcy's fces. <br />o*", C/r(/zt Appricanr: gArco k )A"- <br />, TCENS <br />NECI ARATION <br />I hcreby atfirm undcr pcnalty of pcrjury that I am liccnsed undcr provision of Chaptcr 9 (commcncing with Scction 7000) of Division 3 <br />of thc Business and Professions Codc. and my liccnsc is in full forcc and cffcct. <br />[-iccrtsc al 1,, ... <br />g <br />I t,-^.,..n Numbcr: <br />(tro z4 <br />o*", {/il/tt t <br />W <br />I hcrcby alfirm undcr pnalty of pcrjury that thcrc is a construction lcnding agency for the pcrformncc of thc work for whhh this Jrcmil is <br />issucd (Se. 3097. Civ. C.). <br />kndcr's Narc: <br />[.cnder's Address: <br />APPLICANT DECLARATION <br />I trcrcby aflinn undcr pnalty of perjury onc of thc following declarations: <br />Dcmolition Permits-Asbcstos Notiflcation Fcdcral Rcgulations (Titlc 40, Part6) <br />_Rcquircd l,cttcr of Notification <br />_l certify that the fedcral rcgulations rcgarding asbcstos removal &re not applicable to this projcct. <br />with all City and County <br />and County to cntcr upon thc <br />abovc nrcntioncd proprty for inspcction <br />Applicant or Agent Signature:_ <br />Pernrilce n$nre <br />Site-Work <br />Underground <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildins <br />Under SIab / Floor q a7t Dbhr"'(ffibvcf <br />Bondins lGroundinq I UFER <br />Transformers <br />Torqueino <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilings (T-Bar Roush) <br />[Vleter Release <br />Rough <br />Service JMeter rl .. ^ t <br />FINAL a0 7t Dfttr67 <br />Notes, Remarks, Etc <br />-,1 <br />7/r/zoz-z <br />," d/P/at <br />rlrdinanccs