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ELECTRICAL.INSPECTOB RECOBD
<br />OWNER'UII,DER DELCAR TI()N
<br />I ho.hy amrn und F. y of tl.rjury ih r I tr crc fr lmrn rhc Cofta.br' l-i.cns ljw for rhc lollowin8 rcisn (S$ 'l).l l .J
<br />BusnEs ad Pmf.ssion Codcr Any Ciry or County which rcquncs a pcmrir ro onsltuc'. alrcr, ihprolc. dcmlish or Ep.n 1.,
<br />strucrlrc. pio. lo ils issllncc. aho rqrircs rhc lpplicxrr ior suchFrmir b lilc arisncd sd.mnt rhar h.or*hc n licc.scd lur\uAnr
<br />ro rh. Eovnions of ltE aonlr(.lors Lianscd Law (Choflcr 9. ConrmNins *irh Secrn'n 7 x) or Dieiiion:t otrhc Busincs(,nd
<br />Pmfu$io Codc)orrhrr h.or shc k.rcq)r ihcrcfiondn thchs\hforlh..lhg.dcrcmfrion Atrylnnarionolscclion7r).]15hy!n,
<br />lprlicanr lnraFnnit subjsls lnc applicanl ro icivilD.na[yofnol morclhan fivc hlndrcddollun(!5OO)
<br />l. N osncr of rht pn,Fd y. or ay .mpbrr.i sirh s,r.s rs lhcn sh .omf.net i(ri. will do ih. sdk ,rd lhc srtrrm is ,x,l
<br />ic cd orofrcrcrl for sh (s(.7ol,il. Busincsand Pmfcsion\ C.dcr ThcComadols Liccnsc tiw docs nor aDplyronowncrof
<br />rh. prericny *h. huilds or iq'mvc\ rlErmn. a.d wtn' des such trr* him\clror hcrsllor rhmush his or hcr own cmtlnttcs,
<br />Imvidcd rhd such inD$wmds e0Fr ir cnddoroff.tul f.r eh.Ir. ho'cvci rh. huiklnB.r inlPmrcnEnt is old wirhinonc )rr
<br />oro'ryhrion- th. Ow.f Build& will hav. rhL borLi of ptuving thai h. or sh. di(i mr buiu or nryturc thc tmltny fo! lne puqxrc o,
<br />-1.
<br />nsowrcrofrhctotdt. rncx.lusivclyconta.rin8 sirh li.cnsd conrrcrosr,cotr dct thr pmFr (Scc.7(l+4. Busim\\
<br />nnd l\Df6shn C&lcr'l hc Conrr3ct, \ Liccnse t-o* doc\ nor rDply b !nowner ofprc!.dy who hxilds or imtrorcs thcrcon.
<br />a.d who conrmcr for such rmj.rts wirh a C. ndo(O liccnsd luFur.t ro rhc(n"tracrois Liccnsc ljs)
<br />-l
<br />omexcryl undcr Sccrio
<br />Dat. Oemr:
<br />WoRKERS C()trrPFNS,tTi( \l
<br />DICLAaAIIIIN
<br />I hcrch, af,irm und.r r.nllry of pnjury onc ofthc nrlow,m dcclnrurions:
<br />-l
<br />havc nnn will rui ain a Ccnifi.lre ol aotrsc lo Scr'nsurc lor qork$ onp.lsart,n. as Eovid.d for bt S(ri.n :r70o or rh.
<br />L.hor Codc.lor rhc ltrformrmc olrhc wolk L. which thc Ptrmir h hsucd
<br />I hrrt rid qill ,riiirin sorkcrf .otrltiisrri r i'NUrnN.. r\
<br />rhc lvork lnrshichrhi\ pcrn,ir i\ i\sucd. My workc^ con,l)In\nr
<br />rcqltcd hy sc.rion l7fil ofrh. L.hnr Gdc. for thc pcrf{}nNrcc of
<br />i,,. m{r.'n.c .irle! xtrd 'inl.! nntr$.r rr.
<br />lusutan, e t'd"A-h he (or,Peot So',1 )on
<br />.r.rnfuu,or*,l"/-'v/"4
<br />I .cnily rh.r in lht p.noirmncc olth. work ior which thh p.rmit k hsucd. I stull nor enrlo, lny r.$on ii rny nutrRr
<br />s !s ro tEom sut'rccl lo lhc *orkcn conrpc.s.lion la*s ofcllifomia. xnd usE rhrr irl sh.uld trc.nr subFcl h lhc
<br />*or*c6 mmpen\olion pmltions of sdion :l?00.r rhc libor Co<l€.I shall. ronhwirh.r,nlply wirh rhJt povisions.
<br />WAIdTNC: F lud ro uo workcm .om!.ns,rion slcmgc is unlnwlnl. .nd sh,l! suhirl 0n cmplortr lo oinrinll pcmxts and
<br />c'v'l fin.{ ur ro nnc hunJred rhou$nd dolles (!td.n0(0, nr dddirion ro rhc cosr ol compensrion. d!ruscs as povidcd lor rhc
<br />sccrk,n 1076.r rh. titrn codc. mrrcr arnorm/r r.o**,.-:\/4utr--4". b-;n'q- 5u-,.,, UTEAIIDIONIXA(IAB ADEIIASAIIAN
<br />Ihcrcbyalfirmundcrrc.0llyofpcrrlrylh l qm liensl !trdcr nF! tion or(hJlrcr c (. mmnc'new h sRr nn ?Ortr) ol Dirision l
<br />ol lhc Busifts and Pmfcsions Codc. at my liccnsc is in tuU lore ond cflst.
<br />cnsc N0nft.,: I g
<br />b/)!l>-,J+
<br />CONEIIIJCIIANIINI}INCICDNCI
<br />Ih.rcbyalfirmund.rFnallyolp.rrrythatlhncn0otrnruclionkndinSoscncynrlhcfqfornBmeor'hewor*fitrwhi.hrhisr.rnilis
<br />hsrcd (scc 1097, Civ C )
<br />AIIUCANLIIECI.A&UIAN
<br />limbyafiimunds pcnolry ol pcrjury one orlhc lollouin8 dsharioo\:
<br />D.N,lirion PcnnirrAsh.sos Notilic nrcdc l Rc8uh ionr (Titlc 4{). Prn6)
<br />-Rcquncd
<br />Lctrcr oi Noli'ic{rion
<br />I r.ni,rrhrrilr. riJcr lrgul.riotr\ Attr i'r! \h.snx rc rrnldrc trorrt\rlicdhlc ro rhr fmjccr
<br />I ..diry r,N I havc rc rhis,lpliLarion ind nrr.rhai thc t'lr i.n,marn,n iscotrc.r lasrsx,.on,plywirhrllCiryrnd(t,Dnry
<br />ordinmccs Md srdc tjss rcldtitr8 to buildinS consrrlcrion. .id ncrcbynurhorizc rcl,rcrnlllncs ofrhis Ciryand Counry b.nro upotr d.
<br />rtxlo trrtrri(rcd rmncn,f(tr i'I
<br />Applitxnl or Aq.nl Sis$lur
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas. Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondinq / Groundino / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Solfit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />Rough 6'rr/* Slc iLtP2+&
<br />Service lt/eler
<br />FINAL [ro\\q I tAbifi\
<br />Notes, Remarks, Etc v
<br />Pole Bases
<br />lvleter Release
<br />Enr'rrtrr.fo s
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