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APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Si gns (monument)
<br />Life Satety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Bonding i Grounding / UFER
<br />Transformers
<br />Torqueing
<br />Air Conditioners
<br />Rool To p Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Wallg (Rough)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rouqh)
<br />Ivleter Release
<br />Rough
<br />Service lVeter ,tl2Alla''ft1^h trDrl ft-z/
<br />Notes, Remarks, Etc I II 17
<br />ELECTRICAL-INSPECTOR RECORD
<br />OWNER BUN-DER DEI,CARATION
<br />I ncrchy rfinm und.r pcMlryoI|xjuryrhar I an crcnpt rn,n rh. contrt)s-Liccn* l-rs ror lh.IollowinS drnnr lscc.7oll.5
<br />susitrc\\ a P.ofe$ion C{dc): An, Ciry o! Counry whEh rcluncs i IErn k, oarrucr. allcr. improve. dcmlllh r rNtr my
<br />srflr.rurc. pior t. ik issur c..3l\o rdquir.\ rhc rpl icunr l'orsuch lErnir ro filcx sigtrql {arcmnr rhlr hcor +. is liccntud.pdr{ur
<br />t, rhr F)rnions of ric Conl@roas l,icensd t-ar (Chiflcr 9. C.nrnrrciru wilh Sc.tion 7(xx) of Divisnrn :1 ol rhc Businc\s ind
<br />Pmrcslions Codc ) or rld hcdr\h. i\crcnpr rh.rciionandrhc hnsn fo! rhc lllc8ed crcmprion An, violarionotSccrionT0ll5 hyany
<br />rpplica for ! p.rnrn suhjc.s rhc rprlic,trr ro,civilt.tr,lryolior'tuncrh,n livr hundrcddollrh ($5dr)
<br />l, ,s osrcr or lh. popcny. o. my .ntk,rtc\ wirh wa8$ as I hcn $L conpcNar ion. $ill do ihc sork ard rlE Frturm n tur
<br />inrctucd or olrcrcd for soL ( S( 7l}14. Busircs .nd Pmf.snns C.dc 1 hc G)nrknr\ I-i.cnr. tje d..s nor rpply r. r. owncr of
<br />rhc pDpcdy q,fio noikLr or iqmrs lbcmn. od who d*s sKh M* hnnscllor hc&lf or lhnrugh his or hcr osn cn!,lo)rcs,
<br />Imvidcd rhar such ihpn,kftn* m nor inrcndcJ nr ollcql lor vL. Ii horcvcr. thc huiliins or imomEnEnr h hld wilhin onc ru
<br />.f compLrbn. rtr O*n.r Bniltr will hlr rhe $.rden of l)Irvin8 lhat hc or {lE dn mt huild or iDpmv. tlE pmt6y for lhc puqbc ol
<br />-l-a\oNrcrofrhcpm!.ny.a.rclusivcly$nha.ringwiihliccnri.onta.tnr,onnfl.rrtrlr.|rrISr.70rU.BunN$and PRfcstDCodc:IhcG'nrrucloisl,iccnseLo*docsn.lofpltr.anoBncrofPlotc y who builds or im[ovcs rhcrcon-
<br />rnd qho RNnca rft su.h !tuj(k wirh a c.mtu b(\) licenrd rufiuNr b rlr Contactn s Ltco\c ljw )
<br />IdD.rcn{,!tr crsc.rn .B &PC fttrrhisrer$n
<br />D.ler _ _ ,- _ Orre.:
<br />wonxrqs. coirPflts,rTxiN
<br />PECI,AAAIAN
<br />I h..cby afilrnru6d.r p..,lrr.rFrjuryon.orrl'c tolb*i.g d.chr:tions:
<br />I hrvcdxl willtrrinrdrrCcnin.dr..lCoi{ n, Scllrlnsurc ln. *orkcs $nIcn\nri(,n. rs pori{lcdturbyS..rn{17(X)olrhc
<br />bhin Grlc. I(tr rhc Il.rlbnntrrcc .l rhc sork r'orwhich thc pcnni, h n$cn
<br />-lh.!c
<br />rnd willnrinrrtu workcN .onp.trsarn insuram.. as rcquncd hyS..rn,n:17(X)ofrh.lih.rC.do, forrhc tE ornDn.col
<br />thc *ork ld whi.hthis pcnil is i$u.tl MyworkcB .. r!.nsdri.n inrutuicc.atriod lricynumbcr ml
<br />Poli.yNumh.r
<br />I ccdrfy rh8r in !h. p.rfonBn.c otrh. work fu which rhis Frmir is i\sucd. I \hall nor.npbf arty p.rn,n nr iny tnrnncr
<br />v, !\ ro bcom sul,jd lo ihr work.n' co'nlcns.l ion hws of Crlifornin. 0 oselh iflshould hco.nc sub]cd loltc
<br />worlcn co.Den*ion povnionsolSdion 37(rOolrhc Lihor Codc.l shnll. tunh{ilh c.nurly silh lhos t'iovhions
<br />I&NIIAICDONIBDA!.AGINCI
<br />I h.rcby nlinn undcr rEn0lty of psjury lhal lhcrc is o conndcrion bndinS lgcncy for lhc Isl'ormncc oflhc *orl lor *hich rhn rarmir is
<br />issucd (Scc :i097. Civ, C )
<br />AIIIICAXLDECLAA{UO!
<br />I horrry alllm undcr Fnolr, of ri.rjury ore of rh. lollowin8 'ialarar ions:
<br />D.nnlition Pcnnih.Asbcsros Nolific0lion Fcdcral RcSuhlions lTnb &- Pnn6)
<br />-RcquiEd
<br />Lcllcr of Norifi calhn
<br />l.cdil,vlhrr rhc lidcrrl rcguhrn,Ds r.gml'ng rshcno\ r.nrvrlrrd nor rntl'.rhl! r) rhis r.J..r
<br />-l
<br />ccnilyrlu I hrvc rcad this aptlicorion a.d sat. rhd (hc rtrvc nrroflmrion ir..nsr.l !8re lo.omplyvirh rll Ciryand Counrt
<br />ordironccs md Sllrc ti*! rchrine ro buildins.on(rudion. od hcrcby autkrnc i.rccnidn$ orrhis Ciry and Counry t, c .r dF n rhc
<br />lhove mc ioacd prcpcny for ins!(lion rruTnscs.
<br /> ppli(xnr or AI.nl signoluF
<br />Pole Bases
<br />Under Slab / Floor
<br />Sub-Panels
<br />FINAL
<br />WARNINC: Fdhrc lo slrc worl6 ompensation coveEsc h unlavtul. and shlll rublcd an cq)lo}!r ro dimin,l !.tulli:r aid
<br />civil lincr !t ro one hundEd rholsand doll6 (Sl0o.(x)O), in addnion ro rh. cosr of.omncnqrion, datugcs !r ptuviddl ror the
<br />sfrri.n .1076 of rhc Litq col€. inrrei 3nd arbm, \ feci
<br />Drt.: _ ___ Applldnr:
<br />LICF'NSED CONAIACT(T!I
<br />DECI,Af,AIION
<br />I hcEby am.mundcr pcMlly of pcrury lhal I Bn liensd undd povision olChopts 9 (omErcing wirh Scclion 7000) orDivhion l
<br />of thc BusiNs ond Pmi.ssions Codc. 0nd nry liccnsc h in rnll ntre md .ftecl.
<br />I ., tr.( r..
<br />l)rrr (.nrrirr,,r
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