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ELECTRICAL-INSPECTOH RECORD
<br />APPROVALS DATE ID/SIG,COMMENTS OWNIIR BUILDER DELCARATION
<br />I hcrcby rrfidn undcr p€nally (,r pcrjury rhal I am creq,l r.on rhe conlrocloF l-i.cn{ L,* fo.lhc lollowing rcr$\(Scc.r0ll5
<br />snsircs 3nd Px,fc$nrn Codc) Any Ciry or Coonrt whi.h rcquncs a Frmir t, .onnrucl. llrer idpilrvc. dcnmlish nr rcnln 'iv
<br />srru urc. pri(trlo n\ i\suatra. aho rcqotcs rht,tpli.tu fo. such Pcrnri ro nh i si8rcd slllcftfl thd h.or shc h li'cnkd puisu!trl
<br />b rh. l/olisions oflh. Conrocxtr\ l-icctrscd Law (Ch!tr( 9, Com'rcncnrs $irh sc.tion ?uD ol Dithion 3 of lhc Blsiness antl
<br />Prolc$ions Code) or rhar lr or shc h cxcnPr rhcrcfrom and thc basis lor rhc !ll.!cd cxcmplior Any ri.l.lionofSccrirn 70ll'5 bv 'trv
<br />{plica.r fufu p.mi subj(k lnc lppli.n to rcivillcn.hyofnor n$rcrhrn l'rvc h!d{d dollms ($5(]O).
<br />L $ owrcr ot rh. pmFny, or nry cmtlorces sirh er8cs trs lhcn eb comlxnqr ion- will do rrt woA otd tlE sr rmi( n'i
<br />inrcadd or orlcr.d fd slc ( Ss.7044. Bu\in.s\ ond ftofc$n'ns C{xlc 'I hc Clo.rrloi\ !-iccn* tir docs nor !p y ro sn owncr ol
<br />rhc nopcny vho lDilds or iighv.s lltrmn. u sho d{f,\ skh M ( himscll or h.r\clr or thmush his or h.r oqtr cmplovce\'
<br />trovidcd rhrr strch impmwmft m , inrc*ld or ofilErl ,o. qlc. ll ho*ckr. rhc hoildin3 or iqrov. rnr is sld wirfiin om )td
<br />of conDlcli,n. rlt Ow .r Builds sill huvc thc hurdcn of povin8 dmr hc nr sfi. did nor huild or nwot ih. pmttnv for rhc Nq'$ of
<br />-1.
<br />tr\ owtr.r oih. lopcny. am crclusivcl! conrmcrirs uirh litciscd .onlraclffs ii, L.n{d.t lh. !)rqd (S.. 704-1. tlusrcs
<br />Md Pmrssi.nCodc'lheContnl.rsLiccnscL!*doesnorrpfrrioanosncrorp.opcnv$hohuildso.irPtovesihcftotr
<br />0nd who q,nta.rs ror such pmJcc( {irh a Conhcro(s I liccnsed l) rsunnr o rhe Conrra.ror s LiNnsc Llw).
<br />-l
<br />rncrc'nfl undcr sedion-. B &PC ntrrhisrcrs.n
<br />Doler Orn.r
<br />w(rru(c{s' calMPFNsATloN
<br />DEII,ASAIIQN
<br />I herchy afinn undcr Fn.lryofFrjuryonc orrh. followin8 dcclnrurn,is:
<br />-l
<br />have dd will roinla !CenificorcorconsrnlloSclfnNlrein,workcH conrpc,sarion. is !,ovidcd tor bv Scction l7d)orrhc
<br />Llhor Codc. lor ih. FrfornMc of rht wo* lor which thc pcni is nskd.
<br />-l
<br />h.rc and will m inr,ir workcr' comrcnsutio. insur,rcc. !s reqltcd by Serion 1700 o, rh€ tibor Codc. for rh' p'rrormmce or
<br />vt.d
<br />sFrnrir i. isrucd My*orkds .o,qr.tr\0rion iNulm.c.anicr aftlJxrLi.ynunrhj! c:
<br />\ )ril ([^ fl^<\ I rq
<br />t c.nilylhar in lhcFtrr mre of rhe work ror qhich rht Pcirnil ii i\\ucd. t sholl nor crylov ,.v FGnn in anv unmr
<br />so as ro bc(nB {bi.d lo rlrc wo,lers ofrpctrsirion l.ws ol Cdlinhir. rml l8rcc rhnr if I should h..onrc slbjNr ro lhc
<br />wofiqs comp.n\ari.n pmvhions otsccrion:tTooofrhc Ljhr Odc.lshall. fonhsilh comlly sirh rhor lmvni.ns
<br />WARNINC: rril!rc ro $.urc wortcn conDcissrn,n .ovcrdSc i\ unl,qtuL Jtrd shill suhicr an . rplovct to m'ninrl lEmllis lnd
<br />civil fincr un h onc hnndnd lhousenn
<br />Scdion 10?6 Dr rh. ttrtDr Codc. i fc{
<br />o,,., 11.2--(0.
<br />lEqI,Af,A:IQN
<br />I h.rcby smrm undcr rrnrlty of pcrjlry lhal I m liftosd u.dcr Fovision of Ch0flcr 9 (omftn in8 wirn Scclion 70ml 'r Division :l
<br />or rhc Busims and Pnfcisions Code. and my licc.s. is in rull lorce lrd eff(I.
<br />oool go
<br />J410-*"^*,,
<br />CoNSTRI](I'f I(IN LENDTNG A(;FNCY
<br />I hrmby amirn lndcr F.ahy or ,'.rjury rhar lhcc i\ a coBrtu.lion tndins ,!.my ror rhc PerformRc of th. work for which thh [lanir n
<br />kruen rsN.3()97. civ. c.).
<br />APPLIC N'T DF(]I ARr\TION
<br />I h.ehy atinn uMcr l..!lr, olFrJury o.c ofrhc r'ollo*ing d..l,artuns
<br />DcmnIn,n Pcrmir!Asb.slos Norili.arion l'cdcnl Rcgulari{]ns (Tirlc.10. PrnO)
<br />Rcquncd krrcrnl Norill.diotr
<br />l..iilyrhrr rlt ,rd.rrl rc-trlii,)Ds r.gxki'tr3 nlhl{o( rcnnnr]r. tro1rr)lli.rhI h rhis Pn!.cl
<br />k,-, .."i,r'n,,, u"'",""0,nn,rn,h com.r. I a[re to conlllly wnh tll Ciryrhd Coutrry
<br />,trtli'rrfrc\ x lSr c lr$rrc[ri',8 !i t,u ldr prcscnorn$ olthh Ciry rnd Counly ro cnrn uPn df,
<br />Appli. l or AE.trl SiAnslurc 9"'u A-"-
<br />.7.L_t a.
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safetv /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER
<br />Transformers
<br />Torqueinq
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Solfit Rouqh
<br />Ceilinqs (T-Bar Rouoh)
<br />Meter Release
<br />Rouqh
<br />Service lt/eter
<br />FINAL g /3,/$1t{4V
<br />Notes, Remarks, Etc
<br />Sub-Panels
<br />lhovc rnrnrtud ln)l.ny l'or
<br />I
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