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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDDR DET,CARATION
<br />I hd€b! trflinn und6 pdrlly of p.dury lhal I d ex€,npl liom thc Conracro6 Licms. tnN lor lhe followin8 rcen (Sd.7q3 1 .5
<br />llusirBs d Prolsion Cod€): Any Cily o! County \hich rcqund a pdnn to conslrucl. .lta. i provc donolih or qtrt &y
<br />srndre Inor ro irs iisud.c. als rcqun* rhc a$li.Mt ao. such Fflnil lo file a sisned slatdnol thal nc o*h. is licdkd puEUMl
<br />b rhc provisio.s ofih. Conractois Lic.nsed t,N (Chaprs s, Cohnn ing $nh Sction 7000 of Division I oflh. Businds and
<br />Prefesnros Codc) or lnat h. or sh. ir dcmpl (hd.6on dd rhc bsis lor rh. all.s.d .tm ion Anyviolationofs.dionT0ll sbydy
<br />aptli.adforapdnhsulrdsth..pplicanlloacirilp...ltyofnol'no.eth fivc hundr.d doll-! ($500).
<br />l, Li osn6 of rhc lrolEny, o! m, chplolc rvilh 1v.86 s lh€t ele ompdsslion, sill do rh. wolt Md lhc stflrlE b nol
<br />inrc*l.d or olts.d lor el. 156.?0.11. Busins and Prol6sioN Code llE (ontiadois Licos Las do6 nol apl,Lv lo e o\rr of
<br />ln€ p.opqly sho builds or i'nprov6 rhd6n. md \!ho do6 sn h $.* hims.lf or heslf or Ihroush h6 or h6 otr6 anplorc,
<br />provid.d rhar suc[ imp.ovomis d. ml idodol u onr.d ror elc lr. horvac. rh. Itildin8 or improlml is sld rvnhD onc )q
<br />6f.ontldio( (hc ownd adda rvill hnvc fi€ htrd€n ofpro\ins thal he or shc did @r build or impm\ c fic pmpsty for th. p!I!o* of
<br />!. 6 otr no o f the ,.opdy, an cxclusirely contractng Yirh licm.d .onr.doB ro consnd lh€ [ojccl (Sa 701-1. BB'n*
<br />Md hnlciin ( odc: l h.cont.clois Liccns. L.w do6 nor apply to dr o$!s orprop.ny \rho boilds or inpror6 nEon.
<br />.nd rho conh0crs lor such [oje.s $irh a Co rado(9licdied pmmr ro thcConlracln s Licmc LaN].
<br />I am c\.Npr trnds S(tion
<br />lv9tr6DB[:lAu88lSArIOr
<br />DICIAATIIAI
<br />I h6ebyamfln trndc. pcnalryolpojuryoneoalhe follo\rillg d(lmriois:
<br />I have and s ill oei.rain a C6lificarc oaconmr lo S.lainsure lor Mrk6i compdsnrn. ar Fovid.d ln bt sdio. 1700 of ln
<br />Labor Code lor thc p6 tomanc€ o r lh. *ork ror $iich rh. pdmir is istrcd.
<br />rf halc.nd$illmainl.in*ork6compcNalioninsurance,drequiEdbysdrion1700oflh.tUrr(-ode,forlheptfomM.cor
<br />sork lor Nfii.h lhis p.flnit t istrol. My sorkss conpssarion insurd.. cmid and policy .umbd 6.
<br />,*,",,011/wl,v i (ltv'l ZVrt Ll*
<br />*,,"r*."* hrL(D,lt (2l3 ,,r',,", tl lr lZuzo
<br />lcdiryrhar i.th.pdfoman.eofrh.$ork lor (hich rhis pemn is issu.n.l shallnol mploy.n! p6on inanym.nn6
<br />$ s lo t .om. sobjar lo lhe *ort6' comp.el trn lass ofcaliromi,. and +d rha' ifI shorld h.comc srhj6l to lh.
<br />tro.n'conpNlionprevisionsolSation1700oflh€liborCod€.Ishlll.fonh$nhcomPl,$ilhlhosp,ovisions..
<br />W RNINC Fa'ltrre kJ *uc \.rl.R' .omp6erio. .o!ms. is mla$ful. ond shall iubBl tu dnplold ro rimiml F0hi6 and
<br />civil fin6 up ro on hundrd Ihousnd dollN (3lL'0.u)0). in oddilion ro lhc coe .i cnnrp.nsarion. dm.8s N providcd for lhc
<br />s(non 1076 olrhe bbor Codc, inls6l ad allomev s 16
<br />""",t ldlzozo nnn,r-"i,.rr.rlz-',r0.?.1(tJ A l{9/H1
<br />DlqJa Ilo!
<br />I hcEby amnn under poahyorp.rjury rhar I dn li.oBod unde Fovision ofChapl6 o (connncncinr trnh s.cri.h 7000) olDivision
<br />ol rhe lrusir6s.nd P'ot6ions Codc. ud nryli.tu. is in rull for.c md.llecr
<br />c q?z
<br />*" rl qlzrao "".'-","., Vlallr+ <.p\ae
<br />CONSIA.UEI,IO!-TENDITG-AC.EII:I
<br />I lE b! allnb und( p.nalty of pdjury Ihal lhtre s a coNtruclio. ldding agdcy for rn pdlonn cc ol lhc {o* ior \tich lh$ pdnn b
<br />i.su.d(s* .l0g7.ci! ( ).
<br />4!r!!c4.MDEClAlAUa!
<br />, hsd! afinn undd toalry of psjury on. oalh€ follorvins dEldaliont:
<br />D.nolnhn Pennl^sh6ros Notifi. ion F.ddal Rqul ions (Till€,10, Pan6)
<br />Rcqunen Ldrs olNoufi caln n
<br />I cmilyrhar rhc finqhl rcrulali.ro r.ardi.g dbclos r€mov.lale nol ippiic.blc to lh's pmjdr
<br />,?,-,**rll d l ha\c r.id llris.ppll(alion drd slale rh lhe atryc'nron (n ii..rer. I.Srero conrply Nith all Cilyand County
<br />r.prsar.rirB o f this Ciry Md (bunly ro mt6 upon th.Sratet Rsrclirinsro buildin8 conslru.1rcn. ad h6cby aur
<br />ahov.,nenxoncd rop€n, lor lnst{cr
<br />ADplicarr or.\pcnr sixnoru'c a """\ lo'lwz"
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Danrpers
<br />Building
<br />Under Slab / Floor rl
<br />Bonding / Groundinq / UFER 2l Ll 1,{J Dkr\1d,*v"(
<br />ll
<br />Torqueing
<br />Sub-Panels
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilinqs (T-Bar Rouqh)tl
<br />lt/eter Release 2 4 Lr-)WM*+9'ltt
<br />Rough
<br />Service Meter I I
<br />FINAL .Z t4 t7<)b*-,41n-+11
<br />Notes, Remarks, Etc.I lr
<br />Pole Bases
<br />Communications Cable
<br />Transformers
<br />Air Conditioners
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