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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILT'ER DEI,CARAIrcN
<br />I hcrclry amnn unds penlhy of !.rrxry rhar I m cx.frpr fon rh. Conr.do* Liccnsc L€u lor lhc following @y,n (s(?011.5
<br />Busincss lnd Pmrdsion Cdc): Any Ciry or Counly whi.h rcqun.s a pcn,il ro con(dcr- lllct, impruvc, d'tmolish or rc|ron atry
<br />sdcrtrr.. [iorro irs issunncc. also rcqutcs rhc 0frlictrllI lbr such pcrn ro filca silncdd,rc@nr lhd ltror she is li.cn$! puuuanl
<br />ro thc pmvisions ol rlE ConrEcror's Li.co{d hw (Chapler 9, Co'mwf,in8 wilh S€clion ?(x)0 of Diltion 3 orrhc ausrn.ss a.d
<br />Prorcs{on* c(d.) orrhar t* or sh. is cxcmpt rhcrcfrom and rhc 6asis lor lhe.lbscd cicnprion Anyvih'ionofSclhn?Oll5$yrtry
<br />applica.l for r pcrmil subjar s thc lprlicanr Ir s civil pcnalry of nrr dft rhan fivc hundrcd dollrs (S5m).
<br />-1.
<br />a\ .wNr .r rhc pbpcny, (" my .mrlo$cs wnh wag.s as rhcn $b compcnsd n,n. wiu do rhc eotl dd rk stMurc is nol
<br />inl.mlcd or olfcnd for sk (Se.7O14. Burinc$ ond Pmfcssions Code: The Contmk, s Liccnse L1w docs not atply lo .n osncr ol
<br />th{ pmpcny $ho h{ilds or i'rjiors Lh.mn. .nd sh. dds skh snk himsclf.r hc^clf or thmugh hk o' hcr own.mployc.s.
<br />prcvidc{ lhlr such imprownrfi n nor inrcdldl or oflsrd ad slc Il h.Mttr. rh hoikjinS or in{,oKcnl G sld *irhin onc r:u
<br />or..llqildinr. rtEopmr BuiBcr willhlvc rh. budcnoflmvitrs lhlr h.or dE did hoild or rTmt lf, pmFty for llt Pl'F,{or
<br />_1. aso*mrolrhe proFny, trmcr.lusiv.ly.onk(ring wirh li..n*dco ra.lus lo coo\rrucl rh F,jc.r (Sft 7{1,14, Busirrcs
<br />tuxl Pblsstu Codc: Ttu Conklctoas Liccnsc La* d@s trol lprly k, sn owncr.rptup.riy who huilds or imProlcs rhcrcon-
<br />and who cnnrml\ fu sxch rtur..h eirh a cohrlcror(s) liftn{d furu{trr ro rhc conr,$rols Ltcn( tiwr
<br />I ! cxcnrpt undcr Sccrion
<br />O{ner:
<br />UABtrE&S:I.;OMPJIi.TAII!}N
<br />ITECIAf,AII!]N
<br />I h.rcby,flirmu.d.r p.tr,lry oi pcrJury orc oflh.lollosir8 delarurions
<br />I h.v. dd will @in(ah . ccdifKlb of conk.l lo Sclr-lnsurc fn workss mmpcn\dr ion. as p&vidcd lor by S.clion 3?00 of ric
<br />Ijhor C{dc. lor lhe perrorosic. or rhc w.rk ror uhhh rh. Frmit h hsued
<br />Jh,vc and will nEimain wortcn compcnssl ion inlurarcc. as Equtcd by S*rion ,l7lr0 ol thc tjhor Code. for lhe tettur@c. .l
<br />thc worl lor wni.n lhis !.mil is issd. My *o*ers compcn$rion insunG.rid dn |Blty.unbcr uc:
<br />("
<br />\
<br />"..5 tu-I<- cDae.|Jt^'t1or l$5. (o p, o€ c4LtU",LP\'^qo1oGltzo t1 tL -t - l6
<br />=al cenify rhnr in rhc pcnnnm..c of rhc Nork lbr which rhistcrnril h is\uc'1.I shrllnor cmpkry anyptMn in anyn nncr
<br />$ $ ro h..om subj.rt ro lhc so slconucnsolion la*s ol Califomi!- andlgEcrharifI stbuld bccom ruhicr rortt
<br />wo&ds.omFnsariotrtmvisio.solSstionlTuJoflhcLltnrCodc.lshall,fodhwirh.ofPly*irhrhoc[ovisions
<br />WARNINCT Fdihe lo *.ue ror*.ts ompcnsotion sv.n8c is unlawtul. and shlll slbjccl an .hplortr lo dimin0l PcEhics and
<br />(ivjl fincr un rD one hudr.d rhouend do)ld l!10o,00o). in addirion to rhe .osr .t coop€n$lio.. drnEBcs as providcd for rhc
<br />/A-';" 1176 ^r,b r ^h..d{.::: :T :[: - _' "
<br />^-,".1'o=!1q.]t-/\ "ffi*I hercby antrm u cryd.ltyof pcrjury rhlr I !m liansd undc. Eovhio. olChapr.t 9 (comn.inB Nilh Sdion 7(x)o) orDilhion l
<br />dl rk Busiftsr ald Pofcr\ioas Cod.. a,n my lc.n* is in tull lora si ei{Nt
<br />/,,**".*.,
<br />(","lj
<br />e*Q **" *-*,, ?B) I "t Lzt-t
<br />".**".., 5oL^ o St.* 12 if o".tl
<br />Lcndcls Addrss:
<br />-
<br />_l..nilirhd rhc Ldcrrlr.!ul .trsft8r rnsr\bc{o!r n,vtrlin nor rttli.xhlc h iln\ nxir.(
<br />I ccnily rhd I hvc rctd rhi{ lpnlicrrn,n mt darc rhar rh. ah)vc infnrdrn is..rc.l. l.Ere bcomdy wirh all ciry ind Connry
<br />Mrptr rnJ h.trh/ {uthM rcnrc{nrdivcs ol thn Ciry rnd Codnryro.nrcr upon th.niltrrryc{ rrrl srarc bws rcldr'lE r, huild'ngr,,n{
<br />nho,frf,nr'.ncd nnn ny ro, tr,srAlitn pu+o{r
<br />/ (( )u)-)
<br />,tpllcrnr or A[mr skmrum: -(**n**..,0n.,, O'qY''Taoitt
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Bonding / Groundino / UFER G,zr-lk v.Ufi),
<br />Transformers u
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soflil Rouqh
<br />Ceilinqs (T-Bar Rouoh)
<br />Meter Release
<br />A
<br />Rouqh JoLn+_[,2c4v >fJknl
<br />Service [t/eter
<br />FINAL 6-25-lS xJ/+,t,
<br />Notes, Remarks, Etc
<br />Site-Work
<br />Under Slab / Floor
<br />t..n
<br />IANSIBIJCIIQN.LIiNDINIj.ACINCI
<br />Ihcrcbyrfiflnundcrpcmlyolpcrjuryrhsrrhcrci\4.-n{tu.rion[Mingdec.cynrlhctcrlonumcorihcworrror*hichlhislsnlilt
<br />issuc'l (S... 1097, Civ. C.)
<br />AfILIIANLDECIAEAIT!
<br />I My!fiir uod( petrslry olp.rjury.m ofrlt r.llowiog dcldrarions:
<br />Dcmolirion PcrnrnsAsbcslos Norificlrion FcdclBl Rcsulario.s tTnt to. Pd6)
<br />-Rcquncd
<br />Lcttcr of Nolilicati,n
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