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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby dmrd undcr pemlry 6f pcrjury rhnr I am cxcmpr frcm thc ConrEcroF l-tcnse l-aw for rhc followi.S eaq,n (Sc?031.5 <br />ausinc\* ntul Prof.ssion Codc): A.y Ciry o, Colnl, which rcquircs ! pcrmn ro consrdcr. ahe,. improvc. dcmlish or eran any <br />{fl.ruE, prh,r b irs irruance. nl\o equnB rh. applicanr ln such pcm ro filc i sisrd slllcftnr rhd lr or rhe ir li.en*d puruanl <br />!o lhc Imvhions oi tlE Conlrock t Li.crsd tiw lchnp'o 9, conmkii* sirh sc.rion 7o0o or Division 3 ollhc Busincs andt <br />Pr.fc$nrns Codc).r lhlt hcorshc G cxcmpl lhcrcirom.nn lhc basis ior ln. lllc8cn cx.'nption Antvhl ionofsetbn?031.5byony <br />,ppli.anr tu a Fnnir snhj.ch rh. lpplicanr ro acirilpcnoltyofnot mrc thotr fivc hundreddollaniS500). <br />- <br />l. os o*ncr ol rhc I'o,)cny, or m, cq,lorNs wnh sag8 rs rhcir $h co'np.nurion, will do rlt wo* ad itr snxim n mt <br />inr.ndcd or orlcred aor {lc ( SE 7044- Bosircs and Pmfc$ions Codc: llE Co.rrocrq s Licen\c tiw doe\ nol aI,Pl, ro u o*ncr of <br />rhc pNncny wtn t{ilds or in{mEs rrlmn- alll *ho de\ sh uo* hrnNclr.r tuficllot thmugh his o. hcr owncq,loyecs. <br />nrovidcd lhd su.h irymwnEnR iE mr mrc lol n offcR{ t slc. Il h,$t$r, rhc hoildinS or inrl,mwmnt is sld wnhin orc }Ed <br />or.rn'nkrb( rh. Osicr BnikLr *illhlr rh.blrdcn ofpovins rh hc or shc dil mr ldild., nryroE rh. popca, for rh. tqrE of <br />l.Lsosrororrhrtmr.ny.rm.rclusivcly.ontacri',A*iriliccnscdcontrctnsbcon(rucrrhcpmtcr(Scc?(}1.r.Buin.* <br />lnd hi,L\sirn Conc ftc C.nlmclff s Licensc Laq des nor annly b o owNr oi polErty who bu ilds o, nnprovc\ ihcrcon. <br />rtrd who cofimch for sn.h pm,c.c Nirh x Cortncbn s) liccnscd Nrurnr t, rhc (l <br />'r.ktr s l-i.cn\. hs) <br />lr r.Nntr tr 1i., Scr.o <br />DEir: O*n.r: <br />woR(rRs aaMPiNi^iiilN <br />OICLABdII!)N <br />I hcehy rfiirnundfi rcnrlry or pdjury onc orrhd ft,llowins Jcchrrltuns: <br />lhrv.ddwillnuirrainaC.dirEarcdlconrnrhSclflNurcrbrsnrkcnconr|rnslri{rr.rsFovidcdf{trhrSccriooS?fi}oarhe <br />titx, c('dc.lor lhc lofoiruncc orrhc wolk lbr whi.h thc pcrnril i\ i.suql <br />I hrvc lni willouinr.in workcr{ .omFnsariotr nsxran.c. !\ nton.d bySc.rion l7(x)ofrh.ljborCod.. fo.rh.t rfoflutrcc of <br />rM work fn qhi.h lhG pcnnir is is$.d. Mrwort$J comr.nsation insurM.c.mifiud Flicy numb.r tuc: <br />. /o- l- <br />-l.crlily <br />lhar in rhc pcrloiinrncc oirh. \'ork lnl $h{h rhn r(irnir ir i\\u.d. I drll nor cmnl.y !try p.ron in any mann.r <br />{, a\ h tf,co'm lubicr Io rhc *orkers compcnsarion laws olCalir.rni( and trgrc ihJr ir I rrDul<l hc.onE \uhicr ro rhc <br />sorkc^ co rFnsnrn,n fiovi\bns ofS(rion ]700ofrhc Ldnr Codc. l \hall. fonh*irh conrply wirh rho* lR,vilions <br />WARNINC: Failurc lo €urc sorkeN <br />civil filcs uI, ro one hundrcd lhousand <br />ssrion 1116 ollhe t.ator Codc. inrcren <br />ompcns ion covcraSc is unlawtul. ond shlll subic! !n cnulolcr to rini.alFnallts lnd <br />dollan ($luJ.UJO). in addnion io thc cosl ofcomncnsalion. dam8cs as plovidcd io,lhc <br />'7^\t- I sx <br />D};ILABAIION <br />I furby l,li,nu.ddpciahyo{!.rjurrlhrlrmliccnscdundcrpn)!i\n ofchrtrcr9($h.rc.ingwirhSccri.n7000)orDivi\i.n:] <br />or rhc Bu\incs Md ltoltsiun\Codc. tr'd my liccnsc h tu lnllture rndrrrtcr. <br />C:lr":-t S <br />,,.iL:31 G 3)qr <br />ca!$rBustrotr.LEtDltc_acElcr <br />I hcnby aafum undcr pcnalry or p.rjury rhit rh@ ir a ..nsrruction lending 'scfty for rhc ll.rr.rfuftc or !h. work lor which liis pcrmi' is <br />hrkd (s( 1097, civ c ). <br />AIILI!;ANLIECIIA.IION <br />I ffiy trtrm undcr p.nahy or FrFry onc orrh rolowine ddlddklns: <br />Dcftli'b. Pcr6n\ Arb€{oi Norificarion F.dedl Rcrllarionr (Tirlc40. Pnr6) <br />Rcquind htrf ot Noriakarbn <br />-l <br />ccnirylnd lhclcdefllrcBulolions rcgarding ash:nosrcnmval ic nor rrph$lc to lhis lro]ccl <br />.nli'irtr.c\ n J Srrrc l-rws tolarirA n) <br />dhorc n'rtr(n,ncd pn't.nr lnr instcr <br />oirhis Ciry Md countyto c.rc! ulon Ihc <br /> Urli(lnl (r A,lcnl Si*nllU <br />i> 5-i-Rput'1 <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 />Sub-Panels <br />Air Conditioners <br />Roof T op Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rouoh <br />Ceilin gs (T-Bar Rough) <br />lvleter Release <br />Rou gh <br />Service Meter <br />FINAL v//L//(eO/W-,(9- <br />Remarks Etc. <br />--+ <br />Communications Cable <br />Notes, <br />.]E *" ' ?" 3a1<6 <br />-r------