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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE tD/stG.COMMENTS OWNER BIILDER DEI,CARATION
<br />'I h.r.by smrm unds pmally of p6july lhal I an q€mpl iion lhe Colnraclo6 Lic@.l2{ fot lh. aolldwins r€Nn (S{.?O]l.i
<br />BusinB &d Prolsion Cod.): Any Cily o! Counry which r.quir6 a p@En to co.ntud. all6, nnprcve &nolish or r+at uy
<br />slrudure. For ro its isudcc. ale equn6 rhc +plicot for sucn p€mil to file . sisn.i slardnol rhar hc or sh. i, licdsd p@umt
<br />lo th. I,o6iore of$. Cont&roas Licens.d &w (Chapld 9. Comen.ins *ilh Sdlion ?000 of Oivi3iof, I of$. Ausins e4
<br />ProaGsiom Code) or thar hc or sh. is cr.mpl rhr.fiom od thc bais for lhe alLscd.xdFioi. Any liolalion ols€clion 7011.5 by ory
<br />upplicanllorapedilsubjdsrh.arplica.troa.ivilp..anyofnolmorcthofivchundr.ddolld(S500).
<br />I. 6 oMs oarh. Fopcny. or oy .nploys wnh *.gc s th.ir elc compasation. wiu do lhc worl and lhc shd@ is nor
<br />inraded ororla.d ior slc (sd.7044. Buin6s ed hoasioN Cod.r'ltc Conlmtois l-ic€@ Law&s nor arpl, ro oMdof
<br />the p6Fty lno boildsor imptuvelhson, d who do6 such sl( hims.lf or hNlf or tlmusn his or he own cmploy€6.
<br />provid.drhrt soch imFovmrsemr htdi.do.o,r6cd forsk.li how6. thc buildins or hriolcffi i!sld*ilhi,on ta
<br />of conpteio( $. Olos Buildd will h,v. lne ,mL, ofproln8 thil hc or sh€ did nol build or iry,bv. dt p@Fi, for th. purpGc ol
<br />l, 6 owner ollhe plopdy, an crlusivelyconradinS wilh licscd cont.clos lo comlrucl th. p@jsr (S*.7044. B66s
<br />od l'iotissbn Codc: Th. Conta.ror's Li.6c Law do6 nor apply lo os'n6 otproFny *ho builds o. inPmvd th6@n.
<br />and who conrmcrs lor such proj*rs wilh a Coit6(o(, ltmdl puuumr lo rh. Contraclois Lic€nsc Law).
<br />I m excmpl undd Sction _. B. & P C. foi this r@n
<br />1L0E(!B[COrdSt;!,tArIA!
<br />DICI,ASAIIO!
<br />I h@by amm undr poahyolFjuryon€ ollhc rouowins dclaralioB:
<br />I hav. .ri will mai.tain , C6rifEd. oaconsl to SelfJBuc loi voi.6 onpadion, 6 Fovid.d aor by Sdiotr 1700 of th.
<br />tibor Codc, iorthcpqfom c€oflhcworl lor sti.h fic pent a i$u.d.
<br />(&r.ve and will maifl.in worl{6 comp.s.tion iBut!trc, s r.quird by S<tio. 37OO orlh. tjbor cod., ror thc PstdmMcc ol
<br />Oc @rt aor snich rhis Fmit i! isucd. My vort6 @mpqE6li,)n isumcc cnio dd Flky numhn 6.:
<br />c*\.,Col-P lM.Y o
<br />,,.*ldc v r{6 Ljq L I lt-
<br />I c.nify th,r in thc pslomancc ofrh. qork aor *hichrhG p.mrn t issued, I shallnol dploy&yFson in &y.mna
<br />$ 6 ro bccon. subjer to th. worlm' comp.Barion laws of califomia. ed osc thlr il I snouk h..om. cubj4l lo lh€
<br />mrl6' onpdstion prcvisioN of Sdion 1700 ollh. Llhor Cod., I sh,lt. aonhwilh comply wnh $o* pmyisioB..
<br />WARNINC: Failurc ro BEc Norld mnrpdsalion covsasc is unlaNtuL dd 5h.11 subj{t e mplo}s ro sininal FEhis aod
<br />ovil nnd up ro on€ hundr.d thoused dollm (S100.000), i.ro (hc.6s oa.ome.nsation. dmaxcs d provjdcd tor lhc t
<br />rjbor Code i.rd6l ud n om.y s
<br />I
<br />DECIASAIIIIN
<br />I hd.lry tm und6 pcoally oa psjury lhd t m licoE d undr Fovbion of ChaBd 9 (.onmocins with S.rlho 7000) ot Division l
<br />ol lh. aulin6s ed PofsioN Cod.. ud my licd* is in tull force dd .ft ct.
<br />C-24 loslLns
<br />t
<br />CONiIAUqIION.LEBDIIC-AC,EICI
<br />I hftby amm undq pqahy of p.rjury lhat lhdc is a constuciion ladinS t86cy for lhc pqfotu . ofrh. work for shi.h lhi. F,nn i!
<br />issu.d (Se,1097, Civ. C ).
<br />APPLICANT DECLARATION
<br />IlEdyaftmundd p.nax, otpdjury on ofrh. aollowirS daLrations
<br />D.nokion Pdnils-Asbelos Notific.rio, F.dsol Rcsulariom (Titl. 40, PB,l6)
<br />Rcqut d L.lld ofNoiicaion
<br />?-t c6t\lr thld th. i.nq.lt sul.tioN Esed,n8 sh€tos rmovai tc nor eplicablc lo this pFjer.
<br />/-.4aSi t * t *"" roa ttis applicario. aid $at. th'r tnc abovc inromaton ir .oner. I .gre to @mply wirh .ll ciry and cou y
<br />ordinm.* ed Srat. l,w Ehrhs lo buildins cotutnclion. and hftby tuthorizc rcp6dnlliv6 o I thi.s Ciy ad Couly 1o 6td upon rn
<br />ab.ve nBIion€d plopeny lor
<br />applisntoraE lSignrrur.
<br />r,*.i,**."rn.i"0, C/,4.1
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Rouqh
<br />Ceilinqs (T-Bar Rouqh)
<br />[,4eter Release
<br />Rouoh I
<br />Service lvleter / /FINAL / lrt(/ )d. F -Lrpnrl
<br />Notes, Renia/ks, Etc
<br />Rev 08'07-20'15
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