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ELECTBICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUIT,I}EX DELCARATION
<br />I hcrchy af6rn u.dcr F.alry oI pcrjury lhnl I am cxcnu rtu'n rh. Ct'nt,don Liccnsc tjw for rhc followinS rc0son (Scc?01,.5
<br />0trsinc$ und Pnac$ion Codc): Any Ciry or Couniy which rcquircs a ,crnit lo constrcl, lllcr. imtmvc. dcfl{lhh nr Erron lny
<br />srrucru.c. prior ro irs hsuancc. aho r.tuncs rhc q'pliconr for such Frmi ro file! siBrcd shrcnEnr thot hcor shc n licenscd pu$uanr
<br />b rh. Frvisions.frlr Conki.r.r's Li.cn$d Ltr* {Chaflcr 9, Con.rn.i.B *irh Sccrion T00O or Divhion 3 of lhc Busnrs a.d
<br />Pft'fc$nns Codc)o.thal hcorsh. kcxcmpl rhcrciro'nand lh.blsh ror lhc allqcd crcnprion. An, viohlionofSerionT0ll.5 hy any
<br />afrlicd ror a pcrnir ruhjcch rhc trrplicant lo dcivilpcntrlrrof..r mr. th,n fiv. hundrcddolldrs ($50O)
<br />l. ns .rncrofrt* ptr,rEny. or n, cmrlorcc\ wnh rascs a\ rhen ek ompcnsxrion- *ill do rhc $.rk a,xl rh. ndu. i. rh
<br />i .nrd or olTcrL\l fur $h (S(.?O14, Busircss ,nd Prof.ssnrns Cdl. Thc G,ntr.rn s Li.cnsc tiw docs mr ilply to 3. o*trcr ol
<br />rhcpn,jdy *Iil htil& or impn)vt\ rh.d,n.3J *hodmssuchso*hinNcllorhcrsclforrhron8hnh.rh.rown. lployccs.
<br />providcd rhd such irnmrcmnh arc mr i cndal nr oflircd n* srL. Il. howcrr. rhc buikliry or impmvcnEnl is sld wirhin on. )rr
<br />or.omplcrt,n. de Oeror Buiucr sillMh rhr hlrLn ol prcvins rh( ts or \he dil nor huild o. inlln,v. rh. F,Fry for lltr puqnr ol
<br />-1.
<br />!sowncr ofrhc prop.rly. htrrcxclusivclycontNnra wirh li.cn*d.ontn !n{ lo constru.! rhc pmlccl (Scc. 7(84. Bn\inc$
<br />did Pl f*sbnCd.:'rhcContr.roisl-i.cnscl-urddsnorf,nplybanosftiofnropcnysh()buildsornnnnrvcsrhcrcon.
<br />aod !ho conr.lch lhr such prjc.Is wirh!Conrracra(s)liccnscdrrucuonr ro rh. G,nirlcroi s Li.cnsc ljs)
<br />I lcxcnrpt utuld SLrlion .A &PC li,rihisrcrron
<br />Drre ()*ner:
<br />.ltl)8(EBgCOlilIlNIA.Ill,N
<br />DIS,IAAIIAtr
<br />I hcruby,fl1nn und.i p.nalryol pcruryonc orrh. rolbsm8 dc.lrbrt ns:
<br />l- htr Codc. nr rhr |xr,nrtuicc I rh. sork fttr *hich rhc pernir l\ i\\kd
<br />Ihrvcandwillnrn dh aort$l .ompcnsarh i.suBn.c,.s r.quncdhySccri !ll00ofrhc LatxtrCodc. nr rh. Frlonuncc ol
<br />rhc *ort for which rhn pcrmil is isscd Myportcn .ompcnsarion insurancc caFicr a policy numher eclqfie fr)n o
<br />q 2zt94f:1)) 0
<br />l.cdify rhar nr rh. lr.rfornBn c olrhc work t'tr wl,kh rhk Fflnir k is\rcJ- I rhrll nor unlllloy rny f.Bon nr rtry nnnrcr
<br />$ 0s r) l$onrc suhrccl ro lhc wo.kcr( conrtnsarn r hws ol Cdlir(fltu. rtrd nsrcc rhll if I sh.uld hecom suhjc.i io rhc
<br />wo,kcrs'compcns0lionpmrisionsolSstionlT(Dollhcl,tn.Cfrlc.lsholl.i.dhtrilhcorply*irhrhosepmvisbn\.
<br />SNri! 1076 ol rhc I r&, Codc. i .'.( &d rr[
<br />'^,",
<br />a,/lo/rte7 7',
<br />DECI ARAT(TN
<br />I hcto$y alfirn undcr pcnJry .r Frjury lhal Ln li.r \crl undc. lnovi\ion .r Chipl& 9 (cohircncing with SNtion ?OOO) ot Djvhion 3
<br />ol lhe Alsinc$.nd Prcfssions Code. d nry liccnse h in tull force ondcilsl
<br />f Jrf,ot:>
<br />,",,**"2(=^l -w
<br />C{INSIBI]CIIOB..LENUDCSCENII
<br />I hcrcbynfiiirnundcr pcnahy of Fiury lhat thcrc n a conslruction tndin8 rscncy ror thc pcrformonc€ olrhc work for whi.h rhis Fnnir k
<br />tsucd (Scc.1097, Civ. C.)
<br />AIILICANI.IIECIdEAUA!
<br />I hcrd,y trfilm uRlrr p.nrhy or p.+r, om of rlE rollowing del(,r i,ns
<br />Dennhtun Perris Ast nos Norificarnrn Fedcr,l Regutaii,ns (Tnb40, PM6)
<br />Rcqxircd Lrncr of N.rifsrion
<br />I rnifv rld rhc
<br />itrJr.cn'ryrhr rhrvr l
<br />*itu rNc\.trd srrrr L,
<br />lid.r lr.grlrrion\ toEddirg !\h.no\ rnnnrlrr. n.t rtpirnhlc k) rhi\ tk)i.r
<br />rcad rhis,mlic,rion Md (arc Ih0r lh. nh'vc nrfonMlio. is.orccl. I r8re tocomlly wnh 0ll Cnrand Counry
<br />\.Dldnls,'l rhllciry aL(i)rtrryt,c tr utnnrlr
<br />ib.vc nrnrorcd preNnt lnr
<br />I'ernrite mnr (prinl)h-LLr &t
<br />*,.sfb/ta
<br />Site-Work
<br />Underground [013t/ tt 3$E*
<br />Li ght Standards
<br />Spas, Pool, Fountains
<br />Si gns (monument)
<br />Lile Salely /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Ufier Slab, t'oot--' tr.*a
<br />€ondiDyc-rou nding / U FE R lL/t'UlX 9D 8'6 )lL t> .(6ttz Trlr
<br />rranstormers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Solf it Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />Ivleter Release
<br />II
<br />Rough (\B\\n /11J,1 l")
<br />Service [\/eter
<br />FINAL Hhltct ftnotv*ttt/
<br />Notes, Remarks, Etc -r'
<br />+
<br />Pole Bases
<br />,Q
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