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ELECTRICAL.INSPECTOR RECORD
<br />COMMENTSAPPROVALSDATEID/SIG.
<br />Site-Work
<br />Under round
<br />Pole Bases
<br />Li ht Standards
<br />S S Pool Fountains
<br />monumentSiNS
<br />Lile Safet /Low Volta e
<br />Fire Alarm / Dam ers
<br />Communications Cable
<br />Under Slab / Floor
<br />/ Groundin / UFERBondin
<br />Transformers
<br />To uein
<br />Sub-Panels
<br />Air Conditioners
<br />Rool To E UI ment
<br />Faclor Wired Unit
<br />Walls Rou h
<br />Ceili S Hard & Soflit Rou h
<br />-Bar Rou hCeilins
<br />ltileter Release
<br />?
<br />Service It/eter
<br />FINAL
<br />Notes, Remarks Etc.
<br />OWNER BUILDER DELCARATION
<br />I hcrcby llli,m under p.nahy ol ltijury rhar I a cxc.rl'r from rhc Contracros Ltcn\c Ir* ror lh. followins du (Ss 70ll'5
<br />l,lsincs\ lnd PNrcsio. CoJc): Any Ciry or Counry whict rcquits I p.mrir ro consflcr. .lltr imlrovc. dcmlish nr mn'n 'nt
<br />srdcrurc. Ein b ils , issromc- !h. rcquircs rhc aPplica lor such lcmil to file r sigftd sttlcmnt rhor h. dr shc is liccikd pursurni
<br />tu rhc ,rurisn)ns olrhc C.nlruclols Lice.s.d riw (chaPr.r 9. Conr@trin8 silh Sccrt,n 7000 ol Division I 'l thc Bnsi'r€* trnd
<br />Pmlc$n,n\ C.dd) or lh{i heorshc is.xcmB dcrcfronond rhcbrsis forlhcallcscd cxcnuiotr AnvvioldrionofSsrionT0ll'5bva'v
<br />rppli.rnr lor apcrmir suhjcc(rh. atPliconrloa.ivilPcn0xyornolmrcthrilvchundrcddollus($500)
<br />l- trs own.r ol rhc Doncn v. .r nry cnrdoler uili N!8.s a\ rh- ir $h comFi\rn I. Eill do rh€ *ork ud f, srErtr' h mr
<br />imdidrd orolLrcd for elc (sd 7l)4,1. Btrsines !.d l!rDr.sn,n\ Codc:'Ih. Contn rois Lien\c lf,s docs norllPpl!
<br />'o
<br />an osrcror
<br />rh. propcny (ho l ilds or illllrok\ rhcE)n. ,id who lk\s n'ch x,I hnnscll ot hrFclf or rhiirSh hn or hcr own cnDlovccs
<br />lrovidcd rh0l such impmvcnEns !.c nor inrcndLrt .r ofliRl for eh li tFsct$. rh. huifling or iqftvcnr.r is sU *irhin orc )ttn
<br />;rcon{,lcri(r rh. Own;r Buiklcr willh.rc thc l,ltdcn orp$virre rhdl hc or shc Jid tror huiklot impnrt thc lnilEnv i{r rhc lury$e ol
<br />I. a\ .*Nr of thc fiopcny, n.r cxclusiEly conrDcring wirh licctrsd conrra.ion ro onsldcr rhc t ojNl (Sc. 7l]'t4 auqne$
<br />t ftlrsshnCodcThcConrrucrorst-iccnscL,wdocsn.lryPlyroanowocrolllropciivwhobuildsornnprolcsrhcr€o''
<br />lnd whn conrmch tor stch poixts wnh a Curracn)n rr lictr$d lununr b !h. conlruclois Li..ns tiw)
<br />-l
<br />n drcnrpt undcr SB_li.n-, B. & PC lorrhisr.*on
<br />Dat€ own.r:
<br />wontPxs' r-oitPnlsl nol
<br />NECI {IIATIiJN
<br />, hcrcty rfft r.d.r pcnollyofp.rjuryonc ofthc followiu dc.larariotrs
<br />l havc mdwill Ein(,in sCcnificlrcofconsc ro Sclf lnsuE tnt sukcF comPc.\arion.s rovidcd ror bv Sarion:l?otl or rhc
<br />tihn Cri.. for I hc perfolfumc of Ih. woA roi which thc tE.rnir t i\sncd
<br />-l
<br />h{vc sid willmintoio workcr' .om!.nsolion insuranc..,i i.quircd bv sdrion l70o ofrk Labor Codc. for lhc p'rfonntrme oI
<br />ihc s.rk lbr which this pcmir is L1sd. Myworksi conPctrstlion insurancc.!riq ond rnicy nun$ct tc:
<br />,r,.,_ ^,.*, Otl\)U\^C0 l.3t o-7 "
<br />-l
<br />.cniry rhrl i. thc n rfo!tu,f,c ofrhc work for whi.h rh( ptirnil h issu.d. I sharl.or enDlov anv p.rcon in 3nvrmnmi
<br />v) !s b b!<,m sbjftt lo lhc workcrs comp.ns.o.n law( olCaliromia. rnd osrcc rhnr irl should t conk \xbiar ro lhc
<br />qorkc6' confcnsdion pmvi\ion\ or s.lriotr 17(x) ol'lhc lirtr Codc. I shlll. rffrhsiih co.rdv *ir h rh.* ,rrovhions
<br />c,vil linc\ up t, oN hund..d rhouu d
<br />::-*"?ili''6']-.
<br />rrsc n u hwtul. ud \hall suhjcct nn cnrPk,$r h aimitra! Pciilrics ind
<br />i', rdditi, ti rl,. .o{ of nrgcs es trovidcd for rhe
<br />Ihcrcbytrlrtnr!tuldrpcnalryoltrcrjlryrhdldnliccn$dundctPmvisionotChuPlcrgl..mrmNinswirhsd6'?O(x))nrr'ivhidl:l
<br />of rh. Busircss ond PrntcsionsCodc. and nry li.eis is in tull lorcc and cffc.r
<br />fs tooa ?zl .
<br />l1.t.t'o YAtv^-
<br />CONSTRTI(]TIoN I FNDIN(: A(;ENCY
<br />I h.rhy trfiirm undcr p.r,lryolpcliuryrhar rhdc is d.otr(nNrion knding.Scncv lor rhc ptrlunmcc 'lrhc v'rk for whichihi! tfnnir n
<br />i\sucd iS... 1097. Ci! C )
<br />lrn,l.r\ Nrtrr:
<br />APPLICANT IIFCLARAfION
<br />I hcNhy dllnr uniLr rcmlry ol p{rjury oic olrhc nnhwin-q dtcl rrridr:
<br />ocnnnion Pcnnik Asb.(.s NolincBiion Fdd.hlRcguhlioN (lnh () Prn6)
<br />Rcqxircd LctrcrotNo!fi. ion
<br />-l
<br />ed if, rhd thc fcdcrsl Esnlnrions Eg0rdins r\trslos dnr,vtl tr. .ot atPltahl. to rhis lnjcc'
<br />ZO (d,ryrh l h$c rcod rhr\ tllllrornn sd $!rdh, Lhc,tnv. inlbrnuri.n i! comcr' I lcd rocomPl, wilfi {llCirvtnd Cou'lv
<br />iJmanc',na Sr:rc u*. rcbrini io buiLdins (ohrdr'oi. nd hcrlbv alrhorizc rertcrcntdilcs orlhh Cilvond Countv ra 'nlq ulx)o rlt
<br />$ovc.Enlioncd potcdy lor ilrspcdt,n puDoscs.
<br />Applidrt nr Agenl SiAnalurc a.?-o
<br />Buildinq
<br />Walls (Conduit)
<br />>a?aRouqh
<br />II
<br />lfre
<br />If,nJc.s AJtIc.'
<br />-
<br />ll"1
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