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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE COMMENTS OWNER BUILDER DELCARATION
<br />I lrrcby oinrm udcr p.nally of Frjury rhar I d etnpr rft,n rhc conrs.lon Liccnsc L!$ lor rhl nnhwing rcron (Scc ?01 1 .5
<br />Businc\! adl Pr.fc$t,n Cdlc|r Any ciry o. County ehih rcauircs 0 rEamn lo ..nsrtu.i. ahc., inlltrovc, dcmlnh or rpln 'n,
<br />strucrur. pri,rr ro s issu.trcc. al$ rcquncs rhc uppliclll Lrsuch Fnni[o filca siSncd slarcmnr rhll ncoi \h. is li.coscd l)ur$6nr
<br />h thc rmlhn,ns of rhc Conkaclor's Liccnki Ljw (Chap,cr 9, Commcminr *irt S.cin,n 7o0o olDivision I oflhe Buri.c* and
<br />Prolc$ionsCode)o!rharlEorshciscx.m0lhcrcfroilmdrhctishiorrhe.llcgedexe'ryln,n.AhyvioltrtiotrofSsli,nT0llSby.ny
<br />lrplica r{r a p.nnn sub.jNrs rh. llplicunt lo acililpcnaltyoinor nrE th,n fivc hundrcd dollrs 1S50o).
<br />-,.
<br />!s o*rr of rhc pn,Fny. or my e'nplores wilt *lscs us rhct v,lL conPcnsdnnr. wnl do thc uott and rhc srdh k fr,
<br />inr,xtcl c orcrcd lor slc (Sa 7(H4. B$incss snd Pr,rc*iohs C.dc Thc ConlEcroi s l-iccnse L,* do* .or aPply lo an ouner of
<br />rhc pmrEny $hl hoikrs or in9rc$ thN)n. md *ho drcs such slk hinNellor hd^clr.r lhftu8h ht or hcr own cmploycts.
<br />providcdrh.r slch imtmrnEnl\ @ mr irrcnd.d or olIc(n for ek Ii h)s.wr. rhc tniHiq or inwowrEnl t $ld wkho om tear
<br />of cohplcrion. rhc O{rcr Blikjcr Rill havr lhc bodctr of pmviry tld hc or $c did mr tDild or imProrc thc pm,sty lor rtt purFo$ or
<br />l. rsowh.rorrhc pmpny. rarcxclusivclyonlracrins *irh liccnscd conrri.ins ro otrsrrucl lhc Pmrcr (Sdc 7044. Busim$
<br />rnd Pntuinn Codc: Thc Conkrcrois Li..n* Law d..s.or,nplylo !no*nc. oaproFrry who bxilds o. imJ,.orcs Iho$n.
<br />and who.dnrmchrorsu.hrlorcchsirhaConrEcro(9li.cnsedtu U,nr lo lhc cbnlactols Lians bw).
<br />]YABf,Ef,I-g)IITEITAIION
<br />DECLASAIIO!
<br />I hcreh, !flirn lndcr !.nrkrollnjuryorE ol rhc followir8 d$lrlln,ns
<br />-l
<br />hrvc arxl ! ill minrain o Ccdir*arc oi Consnr ro Scl trsurc for work.r' .omrcn\aftn. a\ povdcrl ior byScdn,n 3700 orrhc
<br />ribor C.dc. for thc p.rfornune ol rhc sork for which rhc Fmir is issucd
<br />My wor*qs .omrcnsarion insurorcc cnicr siri Fricy numh.r m
<br />tca
<br />t1
<br />-lcrnifyrhar
<br />inllr pcrrodumcorrhc wort ltr whichlnh Pcn.il is hsdcd,I shnll n.r cnploya.yl,cGotr
<br />$ r\ t, trconx suhicr to th. po,kcK ompcnqrion l!*s oaCllitornia, nnd r8rcc rhd ifl snout tEco.rc \obitr ro llE
<br />work. .onlpcns iotrprcvhionsofScclion]?0O.trncl,trCod.,lsrxl.fonhsith.onrflyrilhrho€Povhions
<br />NC: l,rilurc r{r \ccu,r workcrs coNctr\dior ..vcmrc i! unh*iul
<br />cs un ro onc hunncd rhou\rnd dollar( ($l(x),(xxD. in ddirion k)
<br />dtr c.rploycr ti .rimi'rl llrtrxhts trl
<br />tr$riotr. drDtr8c\ r\ pnvnlcJ tur rhc
<br />(
<br />Iltllr!-BJna]
<br />I hcrclryrlijlmu cr |tnnlry.lrcluryrhrr Irnli.ctrk\lundcrprovisi.nol 9(.o f, .n! s(hSc.ri( 7(xxr).ll)trNiitrr I
<br />of rhc llusirc$.M Prol'e$ions Codc. und nryliccisr i\ in full inr..8kl.
<br />R llzz o5.w"t a.,t-",".,*
<br />CONSIIICUIINIENDINGAAEIII
<br />I hcehy nfiinnuMcr p.nalrroipeDuiyrhdr lhcrc is a con$ocrhn hnding !8cncy lor rhc rdfornun.c ollhc wort loi whhh rhi{ Frn'h is
<br />is\u.d {S... I}97, Civ. C )
<br />A.PIUCANLDDIIdAAUIIN
<br />I rurh, Lninn u.do F.tr.lry ofpcrJuryone oilhc aollosirg dccluarn'ns:
<br />Dcmol ion Pcrmirs \lE{os Norili.
<br />'on
<br />r{dcrulRc8ulations (lirlc,l0. Pd6)
<br />k.qur.d Lclc' ol Norih.rri({r
<br />l.cnr[th, rhchdcrrlrcauUri.n!Bs3rdn,xa\h.no\r.trk,vi]r mr.pnlical,lc ro rhi\ ptr+cr
<br />_l c.nilyrhll I h:rr rcad rht aprli. ionMdnrtcthal t i.n ir..ne1. I a8c k, c.mply*irh rllCiryrnd coun!,
<br />odinancc\rn,lsrxr.t-awsrcurinAtuhuiUirucon(rucrn))n7tr r.nr.i.ntarivcs ollhk Cilysnd (
<br />lbotc nEnriomd pn'Fny f(r inst&rion pur|x)scs.
<br />Applic! orAs€nlsisnslrre X
<br />l'srikt n nr rprn,lr: l(l,.v ,c
<br />''";/;[s
<br />Site-Work
<br />Underoround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Lile Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Buildinq
<br />Under Slab / Floor
<br />Bondino / Groundinq / UFER /'1
<br />Transformers tl,[/nA
<br />Torqueino /lt/
<br />Sub-Panels ?s u[ '(\
<br />Air Conditioners I
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Solfit Rouoh
<br />Ceilinos (T-Bar Rouoh)
<br />Meter Release
<br />Rouoh
<br />Service l\ileter
<br />FINAL Pr'sn ,hL
<br />Notes Remarks Etc
<br />+
<br />ID/SIG.
<br />Communications Cable I rn-cxcnmr u.Jc' \(ro. .B &PC f,{ rhi" n'a-n
<br />L.ndcii Na6cl
<br />l.ndfl\ A'ld'..{
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<br />tt
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