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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNDR BUILDER DELCANATION
<br />I h.r.by afllrm undcr pcmlly ol Frjury rhal | {n cxcnrpl fmm rhe Conrtctus Li.cn* bw ror !h. followins rclq,i ( sN 70.1 ! 5
<br />Busirrcss md Prufcssion Codcl: A., Cny or Counry whi.h cquircs a ,cmn to consrNd- alls. imprce, d.mlish nr rcnrir .ny
<br />srocturc, pri( ro irs nsunc.. slso Equn s th. ,!d knnl idr ru.h Frmil ro filc r \iBrcd rlllemnr rhd lt or sh. b li.cntd Purs!
<br />lo lhc pmvisions of lh. CotrrEtols Licensd liw (Cfiaplcr 9, Como.ftid! wirh s..ln,n 7000 o, Divhi.n I orrlf, 8u\in.ss a.d
<br />PmlcsionsCodc)orrhrrlEorsheiscx.dprrhcrcfroo,ndrh.basBaoid..llcsedcxcnrflnnr.Anyviolxihnorsccrion?0:ll5byttry
<br />applicul tn I pcrnir subjdB thc applic,.l to a civil Fnalt, or nol mrc lhsn fivc hutrdrcA dousF (55u)).
<br />L as owtr.r ol lhc top.ny. or my cnDn,ycc\ wilh *Iscs as thcn v'b .onlxtrsdiur. will do rhc work and lhc slMruto is
<br />'k,ri, cnded o,ontrcd lnr sle (Sa 704.,1, Br\in.rs uid ttni\sions Codc Thc C. ra.ktr s Licc.\c lie lloes nor +ply b.tr oskroi
<br />rhc F!I. y wh) bu;lds or impr.v.s thcmtr. ni who d{tr\ slch wrl him\ell or hcnc l{ or rhr)xBh hh or hcr own cmJrloycc\.
<br />,mvidcd rhtrr such impo\rmnN d tur idcndcd oronarcd for {lt lt howcwr rhc hildin8 or inpmvctunr h \old withr.trc y'-rr
<br />olonllllkrion. rhc Owncr auik will lulc rhc hurdcn.f[oving rhl h- or {hc di] rnr ltrild or improk lne pn,Fny for rhc Puqr{ oi
<br />_1. {s orncr o{ rhc pmpcny. ad crclurivcly conts.ring sirh li.cn*d .onlrr(oF ro oNlrud rl-r rroFr ( S.{ 70rr, Busfts\
<br />ad ADfdlio.C.dcrTh.ContaclolsLiccnscLrwdocsnoritplylo!norneroIpropc y*hi, huildso. inDroves rhcrcon.
<br />a.d who conrEcls for such rrejcck *nh s Co.rn.ro($) li€n*d punumr ro lh. Conl,lcrois l,ic.nsc bw)
<br />lrn,r(n,lrJ.rSc(rirnr .ll.'il'C'lorrlri\,.x.n
<br />Dnir Ormr
<br />]IAB&IE:TAMIENIA.IIIJN
<br />UICLABAI,UN
<br />I h.r.by rllirn!u d.r Nn,hy orpcrjuryotrcofrhc lollowins dccl.r.lions:
<br />-l
<br />ha\cand * ill nuinrio a Ccnifi.r. of Conscnr tu Sclf.l$urc fDr workgr conrpcnslrion. as pn,vid.d for hySNtion 17IX) olrhc
<br />t$or Otc.lor the Frforronce ofrhc *ork tu which rhc prr.rir n ir\u.d.
<br />-lharcaftl
<br />aillflrainrain *orlcB c.frp.nsdrhn insnrnic.. ns nqxicdbyscctionllTlx)ollheLltxrG ., ror
<br />'hc PcrfoirMmc ol
<br />rhc work nrwhichrhis pcrnrir is isskd. Myw.rk.s .oDp.nsrion insuruncc clntr lnd polty ilmh.rdt:
<br />I ccniti rh.r ir rhc |fno Mnc.ollhcs'orkrar*hichlhi\pcrn,iri\is\u.d.lsl[lltror.nr/oyinyDcroninanyhdn.r
<br />$i\n,hclrnE\uhJccrt,rhcw.rk.^conf.trsrti, h$\of Crlifomir lnd ll8erhsi iIIsk)uld liotu bjcdtorh.
<br />sorkr ' co.rF-n\nrn,n ,tuvisions oi Scd ion lTlX) ol rhc tjtry Oodc. I shrll. lbnh*nh conllly wirh rho$ lmlision\
<br />IVARNIN(;: Frihrc k, r.urc *orkcr mmpctrsdlon (ovcrdrc is unlasf!|, rtrd \hrll {rhl.d an cnrployct ro simi'd Pctrrh[\ d
<br />civil tur\ rp t) onc hundrcd thousrDd dollrtrs ($|U).UJ0)- i. !ddni{)n k, rlt.oi of.. rfctrsrrion. drmScs ar rn,vidcd ld rhc
<br />sc!tron 10?6 0rrhr liMcodc. mBrcn a,",",4/;Gl/:
<br />DECIAtrAI&N
<br />I hcEby afirnundcr l'cnlhyolFriury rhar I am licen*d undc! pmvhion orChlprn 9(commncin8 *ilh S.cli{,n 7fllo) ol Dirisiotr l
<br />of rhc Bori.csand I'or.rsions codc. &d aryliccnsc is in tull forcc and el'iccl.
<br />-uo rDr66 z f
<br />6
<br />IONSIBI]CUAN.LENIJITj}CDNIJ
<br />IhcrhyafinnundcrtndtyofFrju.yrhorlhcrchaconsrrucrt)nl.ndinea8..cytulhclcrformnccofrhcwor*rorwhkhlhisl)cnili!
<br />i!\u.d (S.. :109?, Civ C.).
<br />a.8PJ,llalLlEClAXAn()!
<br />I hedry .nim undcr lcnolry of pcrpry or of rh. n,lb*ing dcclzrr' ionsl
<br />D.tu)l ion Pc.nirs A$Blos Notific.lion Fcncrol Rc8uLlions (Tnt40.l'n6)
<br />Rcquircd trlt.r of Noliicarion
<br />. 1.!niryrl. rhc lcdcrslrcgulolion. r8rdiry r\t{.r^\,crm!Jl0'. nrraJflr$lc ro rlrtr Pn,rc\lo/
<br />4:alef,rry rhor IhJvc rc,drhr arpl'.di'nn J{,rrrhdrrhcrtnvcirformtionncorccl.Iss6lo..nplywilh{llCitylndCounry
<br />ordinrmc\ rnd Srurc llws rlzrin! ro huildire cotrNdcrt,n. md hcrcby.uthorize rcprcicnrariccs ofrhis Cny rd Counly
<br />ahorc nrnrioncd lro|{ny lbr in\nccrion IAppti..nt or As.nl Sisnsture rK
<br />*"*u* *.",onno, L 'r) Ltz,,'/a4
<br />zlqr )'
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monumenl)
<br />Lile Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bondinq / Groundino i UFER
<br />Transformers
<br />Torqueing
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Solfit Rouqh
<br />Ceilinqs (T-Bar Rouqh)
<br />Meter Release (:a
<br />o0
<br />Rouqh /tld,<tt
<br />Service lvleter - tq tr/
<br />FINAL 6Et't 5D66
<br />Notes, Remarks, Etc.
<br />-t
<br />Sub-Panels
<br />Air Conditioners
<br />t .-**",,Y-.1-V-
<br />L.ndc, r Adddr
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