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ELECTRICAL-INSPECTOR RECORD
<br />OIVNI]R I}UILDER Dt'L('ARA I IO]\
<br />I h$cby amm undd pmlty of Frjury ihar I tun .rcmpt tom lhc Conlmcto6 Licse Liw ro! rhe followins rc&n (Sd 703 1 .5
<br />Brin6s d Proasion Codc): Any Ciry or Cou y whi.h r.!un6 a p-nn ro @nsrtu.r, ax6, imprcva dmolbh or Epar my
<br />sm$E , rior ro i's isudc., rls. rotund rhc ,pplicer for such Fmit to lil€ a sisn.d sralmar lh n. or 3hc t licoa.d p6uer
<br />b lne prolisioN ofth€ Contractor's Liccn*d Law (Cnaplcr 9. Com.n ins wilh Sclion 7000 olDivision I ofthc BGinN dd
<br />ProfNioro Codc) or ltat h€ or sh€ is €rcmpr ths.iom ed th. baris for dc allcgcd cr@Fio. Any violalion of Sdion ?011.5 b, aoy
<br />rpplicdforaFmnsubjdlsth..ppli.antloacivilpcnahyolnolmor.thafivchuodtddoll6($500).
<br />L s o$nr oalhc FoFny, or n, mplotE wilh waSB s $cn $le omp€Nlion, willdo d. *ort a.d dc arudw ts rct
<br />inrddql or olt rcd for 3al. (sd 7044, B6ins dd Prcfdiotr Cod.: Tlc Contracrois Licds lis (t)6 nor aprly ro e oMr of
<br />lhc pmrdy who builds or improv6 tho€i, md Nho do6 such wrl hitu.lf ortficlaor lhbugn his or h{ oM.nployc,
<br />providcd thar such iiproffits ft mr sr6d.d or o,nrai for $1. Il how.c. lh. &ildin8 or nnproml is eld wnhin on. yq
<br />orodrpldion. rh. OM6 Buildd will have ih. bud6 oaFoving fid h. tr sh. dil mt build or improlr fi. p,lpdry for lhe puroe of
<br />I, s omd olrtc prcpaly. m dclusively conrractins with lic.Nd coiradoB lo coNrtucr thc projd (Se 7044. BNhN
<br />and PDfssion Coder Tbc Cont.clors Lic€nsc Law do6 rol apply lo d orvna ol propany wno buildr or inpmvd lh6on,
<br />6nd rho .onlncrs fol such prctds wnh ! Conh.ro(3) liced pursMt Io lh. Co ractols I-ic.M t3w).
<br />I an.i.mpt u.d( Serio. ,S &Pc.lorlhisr.en
<br />vaarEBs:loMrEN$rla!
<br />DEC!A!{!IO!
<br />I hcrebr .ilinn undd !.nally ot Ddiury one ol tte followina ddlsaliore
<br />I ba!. dd *ill @inuin a Ctnincar. olconsr lo s.lfJsu. aor so 6 ompdsarion, 6 povidcd tor by Sdxon l70O of thc
<br />Lrb.i Cod., for lh. poaor:ffice of rn *ort aor {hicn the pqnit ie isucd.
<br />{trlf anrr wrrr mainrain po*c comp€nsalion iEura.c€. d ,equted by S€lion 1700 of rh. kbo. Code for lhc psfom c.of
<br />/,,,^ll:
<br />is i$ucd. Mys,ork6 conrposar 'on
<br />insurdc. .di.r dd policy numbs acl
<br />?r *,a,b2-o€1A'--- t9 2o 2,-,
<br />I cdifr rhal in rhc pdaonMncc of rh. sork lor shichrhis pcrmil is isu.d.l shallnol mploydy p@. i. a., rn@s
<br />s 6 to bccomc subjsl lo lhc $ort6' comFNl ion laws ol Caliiomia dd tsre lhd it I should be.omc subiel to lhe
<br />vork6.onpdsationpsvisionsofS.ctionl70oollhrtiborCod€,Islxll.aonhwithcomplywithlhosproyi3io6.
<br />WARNINC r_ailr. ro so.c {.rt6 .ompdBdion ovd.s. ir unlawtul. ud shall subjal a oployg to dminal rouli* &l
<br />.ivil fin.s up io onc hundrcd thoused dollm ($100,000), in addilion to rhc cosr ol compeBation. doasca d pDvid.d for In.
<br />Setion 1076 oith. tibor Code ima6t &d drom.y s t6
<br />I
<br />DECI4SAIO!
<br />I hcby aflirm ufld6 Fnahy ol psjuy rfial I m li€s.d undd provbion olchapta I (.om@che whh Sdion 7000) ot Divi.ion l
<br />ol thc Asin6 ed ProfdioN Codc, od my licw t in tull fo,e alri .fre!.
<br />a to '> q./ t€y'
<br />/. i4- ZD.:c> 6on1.""1o.
<br />I hmby a,lim ud6 p€oahy ot pqjury rhar rh6. s a connruclion kdins
<br />issu€n (Sa 3097, Civ. C.)
<br />pdlom c€ oflh. work lor which this Fmn b
<br />6III.ICANLDICIA8AIIO!
<br />I narry afm nnd6 poally oipajury onc of thc following daldaliotu:
<br />Dcholirion Pmis-Asbcros Noliicalion F.ddal R.gularions (Tiilc 40, Pdr6)
<br />Rmuircd Lll6 of Noilicrtion
<br />I .dify rh.r rh. loldal r.sulalioc Esedins 6b6ros rmoval uc nor a,plicable h lhi. pojer
<br />tld,.diry riar I halr rcad rhis applicarion d rhar rhc
<br />"bov.
<br />inlomarion n cor.d.I asc ro compl, wthallCnytrd couo(y
<br />o'ii'rncs anl Srrre linr s rrlrrii! u buildiig or1 hdcbt aullFriz rep.6€i'la1iu6 of thii Ciry dd Counry ro ald upo. $.
<br />abovc ncnrioncd prcFry for inspdion purpos6./- tl z"
<br />APPROVALS tD/stG.COMMENTS
<br />Site-Work
<br />Underground
<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 / Groundino / 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 />Ceilings (Hard & Soffit Rough
<br />Ceilinqs (T-Bar Rouqh)
<br />Meter Release
<br />Rough
<br />Service [\4eter , iFINAL -,y/t>/ x l.P/,/21 6/
<br />Notes, Remarks, Etc.
<br />Rev.0B-07'2015
<br />P.rhne nrn.(prtn():J
<br />DATE
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