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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION <br />I hcrcby alltm und$ p.nally ('f Frjrry rh,r I m erc'nfl amr <br />'hc <br />Cd trckr^ Li.cn\c tjw ntr rhc followirB rcobn (Scc 7031 5 <br />ausin.ts ,trd Prurcsion C.dc): Any City .r C.unty rhkh rcqun \ r ,nnril ro $nslfl.l. alrer. inuovc. dcmli\h ,{ rcFt ,ny <br />\rructurc. prinio irs issuk-e..ls rcquncs rhc lprltanr tor suchncmirro lilc o signcd darctunr rhar hcorrh. ( li.cn$d pnhunr <br />ro itu pmvisinrs ol th. Conlmclo s l,iccnscd tiw (Chaplcr 9. Onn,rcncins wilh Scclion 7fix) ol Divisjon .l ol rhc Bxsi"cs n d <br />Profc$ions Cod.) or lhar heorsk hcienpr rhfictrom lnd lhc h6is forrhcalkscdcxcoDrn. Any!tularn,norSc.!ion70ll.5bya.y <br />Dmlicam for a l.mir s!bj.cr\ rhc ipplicur ro r .ivil l)cnrlry of nor mr. rtui fivc hundrcd dolldr ( $500). <br />-1. <br />$ owncr ot lhc popcny. rtr my cmpk'rcs wilh wo8cs as lhct \ne compcn\al ion, will no lhc work !*l rhc dmium h n <br />inrcndcn orofirrcd f.r {h lS( 7OJ4. Businc* rnd Pr.lcsrins C{ic Th. C.nr or's Li..tr{ lrw drcs not .ptly b !n o*mr oi <br />rhe Irepcny aho t[ilds or inrpmvcs rhc@o, ard s,ho des sEh *o.i hinsclfor ficMlf or rhn,ueh hi. orh$ oetr cmrLyccs- <br />nrcvdcrl thor such impmv.nrnr\ N rFl ir cnd.t o. olIcr{ fi, $L. It ho$c!..lhe bui[ing or iqmtmnr is $kl qithin on. ,ttr <br />ofconlFlcik,n. rhc Owftr Bxihd willhrc lhj bu,rlo ofFmving rhar hc or shc dil mr build or irFoE lhc lmFny for lhc puqn$ ol <br />l. rsowftiofrhc ttr.rcny. ncxclusiv.l!.otrtr.rnr! wirh li.cnscd .ontrN.r r. c.nslruct rhc proJd (Scc ?0,14. Btrsims <br />aml lnrlssionCode:rhcConrrlcroisl-iccorcl-osdocsnoroDplyro!noencrofror.dywhohrildsortnnovcsrh.rsn. <br />rnd *ho.{ntru.rsrir\xchpmj..hwirhaCon(a.ro(,li..nscdl)u6unlr,rh.Ct.lhcl.isLi.cnscbw). <br />I rn'cxon,pr trfd.' Sdrrnnr .ll & l'C r,trrh'\ 'crynr <br />l)0lc: ()!.$ <br />UABrI85:!.OI'fINIAIION <br />AEIIABAIION <br />I hcrchy arnnnunds p.nllryoipcrjuryom otihc follt'*ins &clrBrion\: <br />I hav. &rl will rDiorrh a CcdirMre or Consnr ro S.lf lnsur a$ work.s .on[.nsdrion, $ trevidcd lor by Sccrion :]?00 of rhc <br />Lihtr Codc. litr lhc pcformane ol thc $ork a,x which rhc pcnnil h issucd <br />I hrvcan(l*ill 'nri.tuin w.rkcn .o'npcisaron in\urnn... ns Btuncd hy Scd ion lT(x) ol rhc l-ohor Codc. l'or rhc tsnrnEmc of <br />lhc sork lir whichthh pcrmit is nshd Mywork.rs ion irsurrtrcc crFicr ! poli., nun$cr !.c <br />I.tdify rhar in rhcl.rfornEmc orrlt woik fitr whi.hrhisl..mir is i\sucd.l rhrll trol cn{loy ory pcrs ir lnynDtrDcr <br />si as <br />'o <br />tEcom sbid b rh. slxcrs compcnsnriofl hws ot Cllifoni.. a osrcc lh,lilI sk'lld hcnnt suhr.d ro rl'. <br />w.rkcrl conrFnsrliotr <br />')mvhnitrs <br />ol Ssl iotr 3?u) of thc L0&tr Codc. I shrll. lon [wilh comply w ilh rlDs pmvistnB . <br />NARNIN(: Frilur. b ycurc wo'kc^'..n,pcn\rrion covc'xgc i\ unh*tl. md \hrll\uhj(r rn o fk)ycr t) (imir{lp.Mlrics rnd <br />civil fincs up b om hundrcd rhousrnd dolh.\ (S,(D.(x in ddiri,,i t, rhc .o{ of.or{f,Derbn. Jrnue$ !s prcvid.d nn rhc <br />S$ri, :10?a ofrhc l.rtx, C.Jc inrcrc{ rn{l klmvs <br />'"'"' -e////]D&CIdBAIIqN <br />I heoby{firnunderFnatryotllcriury rh l am lienard undcr rrDvhioo otChaprc 9 (.ommin! with Sstio. ?000) o,Divhion l <br />nr rh. Busirc$ otrd Pmfcsiotrr CoJc. and nry liNtrr n in lullforcc &1d cflcJr <br />,/. <br />CAXSBUCIIONIINDI G.AGEICI <br />I hcrchr rffirm undcr ncnllty of perjurr rhar rtq€ h ! onsrtucrion lcnding ascmy nr fic por.nMn.c orrh. wurk lu which lhn pennil is <br />issu.d lscc.1097. Civ. C ). <br />AITTUANLDEII.ABAIION <br />I lrirby urm undd p.nilry orFrjrry on. ulrhr nnldwin8 dc.lrarnrns: <br />l)cn{nirion Pcrmils Asbcsros Norificlrion FcdcrulRcsukrions ( lirlc 40. Punr, <br />-Rc(tuncd <br />bllcr of Nolifi crrion <br />l.cdi!rh,r rh.Icd.mltogu In)nsrctnd r! \bcst^rcft)vrlJc nor {Fli.trblc l. rhn Dm]ccr <br />-l.crrilyrlril <br />I h(v. rcM lhh rJrrlic0li{maod (ardhd dEahvc nrtunnrli{nr is.otrccr lrs,.-k,co'nplywirhxllciryotrdCnu.ly <br />onlinirces and Sr.rc Law\ Eldin8 huildiry.on(rucrion. !'xl hcrchy!urhtriz. lcrc\cnrarircs ol rhu-Cirl rnd C.utrry r) ctrrcr trtnn rlE <br />h rr nrtrrioflcd ptur.dy lor irN <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Salety /Low Voltaqe <br />Fire Alarm / Dampers <br />Building <br />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Translormers <br />Torqueing <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouoh) <br />Ceilings (Hard & Solf it Rouoh <br />Ceilings (T-Bar Rouqh) <br />ft/leter Release <br />/1\ <br />Bough q-28 -18 \"w16) <br />Service ltrleter \x <br />FINAL 1-lr-i k *-v-(-11\ <br />Notes, Remarks, Etc <br />lrn&r', Addr* _ <br />e/tz/zc <br />Communications Cable <br />Sub-Panels