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ELECTRICAL-INSPECTOR RECOBD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Sile-Work
<br />Underground
<br />Lighl Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Ala rm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER /0-i 7 -/9 tLc-7-
<br />Translormers
<br />Torquerng
<br />Sub-Panels
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />Ivleler Release
<br />Rough
<br />/a-/7-t,tLc&I
<br />FINAL e--/8.?)R^ r>2,r 5
<br />Notes Remarks, Etc.
<br />OWNER BUILDIiR DDLCARATION
<br />I hcrcby.iftrm und$ pcn ry of p.rjxry (hd I d crcnpr fmd rhc Conrncron L-iccnE ljw fttr rhc tollowin! r.a$n (5*.7031.5
<br />Businc$ !fld lilolesion Codc) Any Cn, or Counly whi.h rcquiG n F nil r. con{dcr, ,lrd. inrthvc. dcmlish or rcn n M!
<br />$flcturc, rlnrt' irs hsurcc.ulso rcquircs rhcapplicanl tor such,rmil ro n[ 0 siemd (stcmnt rhd tEor shc is liccn{d pusuatrl
<br />ro thc pmtsions ofrtr Co.hdols Li.cnsdl tjw (Ch!rr$ 9. Connn.i.i s sirh sccrion 7fi)0 of Dilisn,n ll .r rhc s8inc$ aM
<br />Pefcsions Codc) or lhol h.o!shc iscrenDr lhcrcliom md th. basn lor rhcllt8cdcxcmplion. A.yliotariotrofSclionT03l5 by mt
<br />trpli.aor forapdmn suhjdslhc appliclnl lorcivil,Enaltyofnol morclhrn filc hudrcddollns (S5m).
<br />_1. {s oqncr or ih. ptulfny. oi ny .q)loy*r wirh elscs ss rhcn {h conDcnslrion. sill d{, r}f $orl ud rhc {turw t nor
<br />inr.ndcd or oficrcd Iq slc (Ss ?(},14. Busincs nnd ProfcssnnN C.dc] Thc Cofta.rofs Li.cnsc L.w docs n.rapplylo on n$Nrof
<br />rhc pmpdy Nh. builds or nnpots rhcmn. !l{] wk, dtus fl.h s{)rl hinx.lfor hLrclfor thn,uBh hh or h.r own cmploycc\.
<br />pR,ri,ld rhlr such inrorr'rnrsetur imcndcdoroftrud for salc ll hoscv.r, rhc hilding or inDmEnE nsBwiriin.myrn,
<br />.l co.naldiotr. rhc Owmr Buillcr will hrE rtE h{rd.n of F,vin! rhar h. or shc did ftn $rilt or i'ram}c rhc ptr,p.iy fff rh. pu{n{ or
<br />-1.
<br />x\ o*Nr.llhc ploptny- urcxclu
<br />o rh,fcsi)nC dc: The Conkrckr's
<br />"nd sho .onrE.r\lnrNchpr+crt
<br />sivcly.onrrncring wirh lirci{d codrndo^ r, rrNrrud rtf, rd!.r (s.. 71r44. Bu(ir.$
<br />docs nor lptlyro anowncr olpro|E y who truilds or nnprovc\ rhercon
<br />rdnl) lic.n{d pu*xa turh.cDnrr.rr's l-icci{ Lrq)
<br />I r dcnrpt trnds Sccrion
<br />^ g -1- tN
<br />ilM l!rUll).)
<br />I tcEby lllnm undcr pcmltyotpcrjury
<br />-l
<br />hnrc ondwill nDinhir rCcnificrrcofCo.snr cll:ln\ur lar {orkcrr r.'np.n\rrnn,. as prcvid.d larbtS.crion lTlnotrh.
<br />L,bor codc. lor rhe pcrLrnEcc ofrhe worl tor shich thc pcrnrit t hsucd.
<br />_lhuvclndwillm nlain workcB coD[cns ioninsur0nce.N EquiEd by s(rio. ]7fi)ofrh. Lab.rCod.. for Lhc Ffornm or
<br />rhe sorh f(n Nfikh lnis lermn iF Gsu.n. Myworks onp.ns ri,n insur.nc. canir rnd policy number dc
<br />-l
<br />ccrlify lhlt itr rhc Frlorrorc. oflhr work roi whi.h rhis p.rnir k ksucd. I \hnll nur .nfl.y sny f.A.n in rny mtrnmr
<br />$ I b trme slbjcd h rhc woricr' onr|Enslrion l0ps of C.lifornir, 0nd .grcc rhar if I should tEcom {bjccr Io rh.
<br />wo u* ompcn\arion p,olhions 6l Scr ion 3?00 ol rh. ltrtn! Co<lc. I $\.11. ion h{ilh comply silh rhos Frvision(.
<br />WARNING failurc n, torurc *orkcis'.onDcns ovcriBc it unlawlul. and \hnll subjcci n .mplo,tr to rirtriml Fnallis Md
<br />civil finc\ ur r(' orc hhdrcd rhousand doll$ (D.ooo), rn nddiiion ro lhc.o{ of.orpc.sarion. d,nuCcs.s lrovidcd aor rhc
<br />Sccii{n,:1076 o, ihc l.}txtr( o& inr.rc(indrrr 'ru&--,^", Y' 1' t I
<br />I ltrch) allnru .rlf,n lryofncrluryI olChrntcr 9 ($nnrc.cnu with Scctior 70G)) olDivision 3
<br />Dr rhc Blsims aoa Pofcrsions Codc. and nry liccnk ir in iull ioRr iftl cffG!
<br />g)NSIAUq&NIENDUiiAGENS
<br />I hcrby aflirm undcr Fnolry of perjury lhor rtrrc h r 6.{dcrion Liding ag.n.y for rhc Frfomn.c of rh. eorl fo. whkh rhis JErnir b
<br />hsucd (Sc.. 11097. Civ. C.)
<br />AIPI.ICANLDECIAAAII!]N
<br />I hrtyafinnundcr p.n ly or prru.y onc or rhe followi.s d(hd ions:
<br />D.mliiion Pcrnirs Ash.\ros Notificarion Fedcrrl Rcsukrions frnt.l0. Pan6)
<br />R.quircd t (d of Norifruion
<br />lnc lcdcralrcEul ions rcEardinS .sbcnor rcrmval !rc n.r.pplic.bhh rhn Frcjccr
<br />Itrv.rcadrhi\rl)|rli.rrionmddrrcrhrihc&'vci nnniri,n, iscooccr lrg'cck'..mnlygirhrllCiry!trd(,)unr,
<br />rrcLtrw\ Rlarir! b buildingcondrucri,,n. rnn hcrcbyrurh.riTc.ctr.scnrrrir.\ofrhis Citya Couiryt,c crulnnrh.
<br />F)prny ntr ir\p.cri(r ptrpo*si___Te,,wfutt
<br />9-1-/{\pplknnr or^arfrnsruF
<br />Pole Bases
<br />Air Conditioners
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Service lvleter
<br />Policy Numb.r:_ExIircs:
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