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ELECTRICAL.INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATTON
<br />I hcBb, s,firo lndcr pcidry or p.rrxry rh{ I m cr.nfl t ,r rh. Cotrtudor Ltcns tjw lor rhe followi.s ?.rw,n ( Se ?01 , 5
<br />Busincss aM Profcsion Codc): Any Ciry or Colmy uhth r.quncs ! Irrmn to .on(rud. 'l!6. improv., {rcmlish or rcp,n my
<br />(rudurc. prd to ils nsumc. sls rcquircs thc rpplk3nt for such [Ermir ro filc a ri!(d (d.mnr rhd h. or shc is liccnsd I,usuanl
<br />r.
<br />'hc !ftvnio.i 01lh. Conrack \ Li.cnr.d hw lchaptcr 9. Commrciry wirh Sccrion 7OO0 of Division I orrh. Butncs and
<br />Prcfcsions Codc) or rhat tc nr shc h crcmpr ricrc{rom and rlE bosn ao, rhc llkgcd.rcrprirn Any vrihrionofScdbn T0ll5 by lny
<br />utplicanr for aPcmit subr.crs thc trpplicanlrr,!civilpcnalryolnor )drhM nv. hundrcd doll&s (Ssm).
<br />-l,
<br />ns owncr of rhc potcny, or nry cmpbyccs wilh wascs as rhct $lc co'nlJ.ns,lion. will do th. work ,nd rhc stulE is nor
<br />i ctrdcd orofiercd lo. sic (Scc.7or4. Businc$ lnd Pn,rc$n,ns C.dt: Thc Cont,.hls Ltcnsc Low docs nololply ro enowncrot
<br />rhc pmFily wt(, builds or irororcs llEm..ond *ho des suh MrI hinsclfor hcEclror rhough hh or hr o*ncmployccs.
<br />,rovidcd ihar snch inDbh,En*m nor int€ndcd ororlcr€d tursk.ll hrsrw. rh. hoikliq or in{,rclcm i\ v'ld wirhin onc yls
<br />of conrplclion. lnc Oprcr Builds will haw the t urdcn of pm'ins lhd h. or shc did an bitl .i inrpmw tE ImFny tin lhc lruqnc of
<br />-l..sosmr
<br />ofrhc pmpcny. xnci.llsivclyc.ftscrins $irh liccnsd conrhcbf k, construcr trE Foiccl (S(. 7o1rl, Bu\ircs
<br />dxi E frsri,n Codc: Th. Conrn ror's Li.c.s. Las d@s nor apllyro 0nowrcr ofprol,cn, sho tuilds o, improkr th.rcon.
<br />lnd *ho conrracls lor sEh I'mjccls wnh a Conhcro{s) liccnscn llusunr ro rh. Co rnciors Lim* tis).
<br />-l
<br />amcxcmpt undcrSelion-. B. & PC forlhh rco$n
<br />IIAXtrEAI.EAMIINSAIII]N
<br />DECI/3AIII}!
<br />I hcrchy rllnm undc, pcMlt) .l l{rJry.trc oflhc Inibanr8 dcclarari{nx,
<br />-l
<br />h.!c udsill nEinioitr rCcnific.rcofConscnr roSclf-lnsurcl *o,kcr' co6pctrs,ri.n. .s povidcrt lor bySection l?0o ollhe
<br />tih,ACd.. ro, rh. ndinrnrn!. nf rhl $mt lor wh(h rhc F.rm F Fsucd
<br />IS,&" -o *',,*,*, *",kcis (nmn(nr nn in\urarce. a\ .cquired h, s*! k n r7{D or $. bhor c'odc. ro, rhe pcrti,mmc ol
<br />/rhc *,X.Jor whth lhn Nm trtr.Jcd Mt {orko| mnFn{rinn 'n\u,sm$nrr rd FlEynumt rec
<br />,.,*q ql2) t<l
<br />I
<br />-l
<br />ccnily lhlr in rh. pcrlornuncc olrhc *or( for which rhn pcrdir is (\rcd, I shnll not cnrplo, any pcson in rny nruncr
<br />{, a\ k, b.dne \ubjc.r ro rhc work.r\ drrp.n\dio. hws ofCdliroxrir. rnd alrcc lhar iil shoukl i.comd sxhjcd h rhc
<br />workds.onil.nsdionpn,vi\ionsofsc.rionlTmolrlrLrh.rOxlc.lshrll.n,nhsirhcom,,ly$irhrho{fovi{onr.
<br />WARNINC: Failure lo ccurc work r' conFnerinn covcBsc is lnl,wrul. rd shall subrcct an .mployer lo.nmi.ul Ilcnllir\ rnd
<br />ciril litrcs up ro onc hunded rhousnd douor (SllD,0oO). in addirnn io rh. con olctnvcnsarion. d.msc\ ar pr.viddl ror rrt
<br />Sarion ll)'76 ofrhc Lalnr Codc. inrcrcn 3nd olromy\ accs
<br />UCIISr:D.l()NIBrlglB
<br />UIT:LIAAIIQN
<br />I h.eby nrmundd pcnrlly of lErjury lhal ! am lienrt undcr Fovtion ofChspr4 9 (.om.fti.8 *irh S.clion 70(x)) ofDivision 3
<br />of rhe BuriEs and Pmf.sions Code. rd my liccnsc is in tull Iorc and r,lecl.
<br />ct+4r,b \q 0+
<br />k {r4r3
<br />CANIIAUSU!}IIIEDI!!;AGEI.CI
<br />I hcrby.ftrn undcr Fn,lry of perjury lhal llEE h a onsldction lcndins.scrc,lor lhc t rfoln,m orrrE work for *hich lhh lErmir is
<br />hsucd (Sa. 3097. CiY. C.).
<br />AEUCANI.IECI.AEAIIQN
<br />I hcrchy dtid unds pcuhy of Frjury oic of rh. r.ll.wing declrmtionx:
<br />ocmlilion Pcrmils.Asbcslos Nolifi caliotr Fcdcrol Rcsulalions (Tilb.r0- Pln6)
<br />-R.quircd
<br />t rlcrof Notificalion
<br />I .Er6 ro @nD|y wnh .I Cny ud counly
<br />ltiEs ofrhi. Ciry mrt Counly lo €nl6 upo. tlE
<br />-," q[\4t8
<br />(4 pDI
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Satety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildino
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilinqs (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rough)
<br />Rough
<br />Service lvleler
<br />FINAL 8 >1\19 /,LldE@
<br />Notes, Remarks, Etc
<br />APPROVALS
<br />Ivleter Release
<br />L.nd.r\ AddrE$:
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