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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrcby omirn undcr pcnrlry (,, Frjury rhar I amcrcm0 lbm rhc Co.rtacror Li.cnsc bw ln lhc follo*ing M$n (SN7011.5
<br />Busincs and Porc$ion Cod.): Any Cily or Counl, which rc+t.s d lf,nnir to consttucl. llrcr, imptuvc. d.,IBlnh or rcPBn anv
<br />i .rurc. prk tu ns hsu0ncc- sl$ rcquncs rhc q,plicdl ror su.h Fnnil lo fih r {ismd surcmnr rhd h.or shc n licen*d luhadr
<br />ro rhc nrovhion\ oftlt Conrn toas Lietrscd Law (Chrylcr 9. Co'nntminB with Scclion 7m0 of Di!i\i.n I of lnc Brsincs lnd
<br />Pof.$l,ns Codc) o. lhrl rEorshc hcrcmnr th€r.fro ud rhc hsis ior tlE olhEcd cx€mprion nyviol,lionofSccli.nTOll5bytny
<br />lppli.d tbr a pcrn tubjels rhr +pli.dnl ro tr .ivil pnahy ol nol mrc lnatr nlc hundrcd dollar (35001
<br />-1.
<br />ac .vmr or lh. pmpcnr, nr nry employes wirh w,!.\ as thcn sb (mPcns0l ion. *ill d. thc etrk rd thc sltrrm n i
<br />iNcndcd o.ofclcd l sle(S6.?Oi4.BusincsrndPn,lcssionsCod.'lhcConkr.t \Liccn*tjwdocsnorsprlyr.anow.cror
<br />rhe F)pcny Nho hoildror nrq)mrcs lheBrn. ml who d(rs skh w.i( hnnsclfo, hcr*lfor rhrouEh hk or hcr own cnrPl.vccs,
<br />providcd I har such intPohmnrs m mr i crd.i or ollcEd for qlc ll h,sc!t.. ttF huildins or iflln)wm ksllwirhinaft)t-
<br />of con{,lcrion. lhc O*ncr Buildc! *ill harc rh. buf,lcn ol pmvirs rh{ he or rhd did kn buiU or iq'rew lhe lordy ror lhc lurr{E ol
<br />-1.
<br />nsowncr of rhe pmtcdy., cxclusivclycoDrraclins wirh li.cn$d cotrrrroF ro coo(ocr rhe,,6jcd (se 7l}4'1. B^i....
<br />nd PmrsstunCodc:rhcConlrdixst-i.cnscLnwdocsrcra0llyro0nouncrorpiop.rly*h(,tuildsori'nprovc\rhcr.on.
<br />an'i *ho.onrachn*su.hlmj.rlswith!Ct.lncrorlrliccn*dpuilunnrrothtConlEctr\Li.nsctjs)
<br />]vaatr[&::.(aullNla.IlaN
<br />DEILISAIAN
<br />t h.rchy affinnundcr pcnlhroaFrjnryonc otrh. fi,lk,snrt dc.l rrio.s
<br />I hev. ..d B ill flinrlin a CcnifErrc.f Conrcnr ro sclf-l6sur. f uorter' ompcrsdriDn. $ pmvidcd nx $y Sd1iotr l7m .f rhc
<br />taborCode. torrh.perlormanccof lhcwort for whichrhc|lcmir h hiu.d.
<br />I hdvc and will nrinruitr workcrs comr.ns,rion ,nsumftc. .s rcqu
<br />rhc $,{Ufl trhkh lhn I).lmir'. F.d,J M, unrklti (nmn n'otnn'n
<br />,."-,' tA)et6g 1')r1<l I dS
<br />trcd h) Shlh{r r "r,,'l rh. Lrhn aiiJr. li rhr ll.rr.rnENc nr
<br />surln( ctrnicrund fl nicy nunrhcr !rc:
<br />-'7k;ooh oUl)l lL to (
<br />-l.c
<br />irrrh"r i.rhc lcrrorronccolthc work iq whichrhhFnn is hsrcd.I shall nol tmrk,y dny t.Botr itr onym!nm.
<br />s .\ t, tf,.oN subrGr ro rh. rorkdi mnp..sdnrn hwl of California. lnd s3rec rhar if I shotrld hccom subjccr io rh.
<br />rnt6i .onp.trs,rion trcvisions of Sccr io. l7m oi lht bhr (1xlc. I shrll. lon h*irh .o'nlly w r h
<br />'hot Pmvnioni
<br />\!ARNIN(i failur h *curc wurkcr\ corpcn\xri{)n cov lr rihtcr rtr .nrdoycr h !rnni,*l n(nrlr{\ xnd
<br />ot c.nlcns rnnr. drtruAcs tr\ ,xolnlrJ ,nr rhcci!il finc\ !p k, onc hurdrcd llnusrnd dol1ln ($l(x).lx
<br />?
<br />ur!lltslral
<br />I hcr$, nflir u cr |rmhrnl tcrjuryrhrr ltrnt ln n*luMcrnn )visionoaCh4lieJ(.. nftn.irA wilh Sccrion ?(X[) ol DNirior ]
<br />f rlt Bun c$nnd PoltsionsCodc. uxl ny
<br />{2q ?5('fl(
<br />Q!iII!L:!-I]A!-LINIlllil;rllill].(.I
<br />I hcshy aafifln und.r Fn.ky of pcrjury I hll rbcre n acon{dcrion LndirB +cncy rot rhc Frromrmc ofrhc work for whi.h rhh Fmir is
<br />issucd (Scc 31197-Civ C)
<br />l.r ili rhrrrhc li'(lctrltu3u xri,nn 'c|x',li sosrcnx,vilrrc nor trJrllicrhlc t, rlri! !roiccr
<br />-l
<br />ccnifyrhar I hnvc fu.d rhis r,,pl
<br />o inaicesatul sbt hwsrhrinS to
<br />ion is comc' I asrdbotrrlywirhall CilyBnd C.unry
<br />rtrrl$rnc rqr.sdDrrrn.\ ol rlr'\ CIv n-r r:innrlYt] cnror rpr rltr'
<br />rtitr. trr.nii(trr,1f()t. ) lnr
<br />,\Dpli(ntrl or,\[rtrl Sixn lu
<br />Eoal\
<br />*,.,x/ryt
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Lile Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER tlll6 fi,t,*ra<U/-l
<br />Translormers I
<br />Torqueino
<br />Sub-Panels ullll{,i1 u'/pWL\-2b/
<br />Air Conditioners I vr
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soffit Rouoh
<br />Ceilinqs (T-Bar Rouqh)
<br />It/eter Release
<br />Rouqh Il'? ltt 'i\'22
<br />Service l\/eter L/t \
<br />FINAL ?-t315 /2,cbj )
<br />Notes, Remarks, Etc (---z
<br />I trrcrcDln unlcr s.cri{,r .ll &P( t,).rhi\rcx$r
<br />lrarP
<br />I (9
<br />U
<br />IIILICANI.DICI.ASAIION
<br />I hhiby aJtnn lndcr pcnohy of pcrjury onc ofrh. fouowib8 dcclaralions:
<br />Dcmlirio. Pcrnik Asb.sros Noliicalion Fedcral ReBnl6iions (Tnh 40. P0n6)
<br />_Rcquned rdrcr or Nolincalion
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