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ELECTRICAL.INSPECTOR RECOR D <br />APPROVALS DATE IDiSIG COMMENTS OIVN!]R BU II,I)ER DT]I,('A RATION <br />I hcrchy allirm unicr l--nally ol pcriury thxt I anr cxcnrpl lionr lhc (irirrcl()rs Lrccnsc l-aw li)r lhc li)ll()wing rctson iScc.70.ri5 <br />Busiilr'ss an(l I'rolissii)n Crxlc): Any Cily or Counly which rcquircs r fEflnrl lo conslRrcl. allcr, impr(lve. dcn()lsh or rl)iir nny <br />srnrclure.pr!)rloils issrrtrcc.rlsr)rcquircslhcappli(antlbrsnch[rnnitkrlilcrsisncJslrlcnEnl lhrtlE()rshcisliccnsol pursral <br />to lhc pruvisi(m\ ol'lllc Contraclor's Liccnscd Law (Chrplcr 9. (i)rnnlcncins wilh Sceli(n ?(XX) i)l Division -l ol thc Busincsiand <br />apl)licrnlli)rrfcrnritsubjcclsth!'npplicanlt)rcivillcnrllyoln(ilnx{'clhanlivchuD(trcd&)llrr\(S5U)). <br />_1. ns owncr ol thc pR)Ndv. or ny cnlpl()yccs wilh walcs rs lhcir solc (otrlFnsrliorr. willilo lhc work a,d lhc slnrclurc ir not <br />trilcflcd orolltrcrlli)rsnlc(Se.7044.Busincssanrll'roli'\si(tlsC()dc:'lhcConhacl()r'sl-iccnscLawdocsnot{pplyk)anowncrol' <br />thc pn)FErly wlN build\ rrr inlprovcs llrrqln. dil who rl(ts sueh wort hitrls.lf(n'hcrsclfor thrNgh his or hcr own cnlp[)yccs. <br />sah). <br />_1. as r)wilcr ol lhc proltny. {nr c\chr\ivcly conlrrclrng wilh liccnrd eo,ilra!lr)rs h) .onslrlrcl lhc pr)jccl (S!'c. 7044. I}ilsurcs\ <br />rnd wh() eonlrilct\ Ii)r su(h p()iccts wilh n Corilra(tnIs) licctr\c(l pulsrxnl lo lhc CoDlracl()r's I-iecn\c l,rw). <br />_l rtrr c\ctrrln und.r S(.ctir)n_. B. & l'.( . Ii, lhr\ rcason. <br />Irale:- <br />lVORKEI{S' ('ONtPENSA-l tON <br />t)EcLAli/\TtoN <br />l hcr chy a l l inn rrxlc'r l{ilxltv r)l pciilr y rrRr ol t ht' litlIrwrng rlc'clarat ioni <br />_l hrvc and will mxintain il Ccnil-icatc ot Conscnl lo Scll:ln\urc litr'workt-rs conrpcnrati(rn. as providcd li)r hy Sccti(u -l7U) r)l thc <br />l-atxrr C(xIc. li)r lhc pcrlirrnHncc ol'thc work li)r whi(h lhc pcrnril i\ is\!e(I. <br />lhc work li)r whieh lhis pcrnril is is\ucd. My workcrs c()nll)cn\rli(nr insurrn(c crn'rcr and F)licy ruillher ilc: <br />rani^r. <br />Policv Numhcr: Exnires: <br />_l c!.dilv that itr thr'l^-rlirrn[nec ol thc w()rk li)r which lhis lcrilil is issuctl, I shrll not cnr|Irv rny pcrson i[ rly ilxnicr <br />so as k) lrconrc (uhjccl lr) lhc workcr\'comfcn\rli()n hw( ol ('ill()rnrr. iln(l {prcc lhll il I \hould lte{}nK suhjcct k} thc <br />IVARNIN(I: Faihrc t(, sceurc w()rkcrs' compcnsi(ion (ovcrigc is unlawlul. rnd shxll suhjcct nn cmdo.vcr t() crinrinAl lEnilli.s ind <br />civil lin!'s !I t) onc h(n(lrcd thou(rnd dollars (l$lu).{xx)). in k) lhc cost of compcnsation. d{nugcs as pro\'tdcd lirr <br />Sccl irtrl l,atxlr (ixlc. iilcrcsl i[d xtlrrncy s ti'c\. <br />I hcrchv nllir nr uDrlcr pctrnlty ol ff,'rjur y thilt I nnr provision ol Chiptcr r.) (crnnmcncinS wilh Scclion 70(X)) r)l t)ivi\ion l <br />ol thc [iil\rlc\\ and Ptr)ltss()ns Crxlc. rnd nry in lull torcc ilil cll(-cl. <br />I-icensc C <br />x"*" <br />Nu <br />(irDlrilctrr: <br />,,rrnr***K^ar'-;- <br />i\suc(l (Scc. -1(x)?. Civ. C.). <br />Ian(lcr's Namc: _ <br />lrndcr's Addrcss: _ <br />APPLICANT DECLARATION <br />I lrrchy allirrn undcr pcualty of Nrjrry onc of thc lirlLrwurg dcclarat ions: <br />l)cnx)lition Pcrmils-Ashustos Nrnilicrti{trr Fedcrrl Rctulntii{ls ('l itlc 40. Prn6) <br />_Rcqutcrl lf, tlcr ()l Nolilicati(rl <br />_l ccnrly thdl th!'lc(lcrrlre!uli(ions rcgiudinS ashcsi)s r('nx)\'ilir. iliil al)plicxhlc lo lllis fr(l.icct. <br />_l ccrlily thilt I hnvc ren(l lhis rppl i(rl!)n ind {lilc thrt llk- xli)\c inl)ril)irl!inr i\ (orrc(1. I r!rcc lr) coilrllv with rll ( ily rnrl (i)urrtv <br />ivr-s "l lhis ( ilv nDd (i)unlv lo cn(d lrnr lh('or(lindnecs nnd Statr'Law\ relntirg k) brilding rnd hcrchv xut <br />atx)v(- R.ntioned pr)[rcily li)r <br />Applicnnl or Agetrt Signill <br />Itertrrilee nrilrc (print <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor ln I n <br />Bondino / Groundinq / UFER vlulrlu tur&4 D <br />Transformers t, <br />Torqueinq <br />Sub-Panels <br />Air Conditioners l,lt Ir 6) <br />Roof Top Equipment lHIf w/r*{/ab/a^v*y <br />Factory Wired Unit /,l <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinqs (T-Bar Rough) <br />Meter Release <br />Rouqh <br />Service N/eter tt It ^bFINALTTT0|ya fiMWUI WD <br />Notes, Remarks, Etc t,