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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDER DELCARATION
<br />I hcrcby ifliirn undcr p.nalty of lcrjury lhll Ln crcq)r lmn rhc conta.roG Liccn* tiw lor lhe rolhwinS n.sn (s(.7011.5 ,8usii.$ B i Protc$ion Codc): An, Cil, or Counly vhich Nquncs r IE nil ro onslru€1. ollcr imrrovc. dcmlish or aD€n rny
<br />{fl.lurc, priorro ns hsx8nc.. eho rqxncs rhclPtltu,nr ttr suchI'cmir to filca stned srorcftnr rharlcorshc b li.coscd !!r{ r
<br />ro rhc povilionr of rh€ Conrracrors l-icenscn Llq (Cho/cr 9. Commtrcing wilh Scclion TOur of Dirision I ol th. ltusincs and
<br />Pn,fcsions Codc) drrh tuorsh. is.rcnfl rh.rsrrod and th€ hsis rh. rhc aucscdcrenflb.. AnyviolarionofSecrion70.r15hyany
<br />appli.anlforr!.rnisubj.rlsth.applrnntto..ivilpcndhyorno!turcrhnrivchunlrcddollul($5001.
<br />-l-
<br />0s owncr oi lhc pmpcny. ot my cnldoyccs Nirh shB.s r{ rhcn Knc ...,pcisar i.n. will d. lrr sork Md rh. sfldm i\ m'
<br />inlcndcd or oficrcd for elc (S( 7014. Bu\incs md ftnfcsionq codc Thc Conlrudoas Licc.sc Law docs nor lrply h !n o! ncr ol
<br />rhn Impcny who t{ilds or irr{ms lhcNn..d wtx) d(B ruch *ork hnns.lfor hcrqlf.r rhftr8h hk or h* own cnqlnyccs,
<br />frtuvidcd rhar sxch nqroktunk rc mr i,r.ndcd orolfcrci ln.sk ll ho*c!.r. rhc liildi',g or n{n*cnrm h $H wirhi'r on. trr
<br />of cotDbrnrn.
<br />'hc
<br />osner Auiklcr *ill horc lnc hurdcn ol,novine tMl hc or shc dil nor build or impmvc thc pn'Fny lbr lhc puqnc of
<br />l.r\u$.rorr,[I)()tant.m,cklo\ivrlvcont ri'13 wirh li..trsd ..nkrd ^ ro connnrr rhI prc]r.r(sc. 70.1.1.Ilulncs
<br />rtut ltrrisirC.dc lhc(,nnhcrors Licctrse LrLv 'lors tror xtflyk) ntro*ncr rrfnrN y wh.lruild\ ur iNfrovcs lh.r.on,
<br />rtrd qho rotrtr.rsfd such pnllccrssirhtr (-r,nrrttr(, licctr--J pur\urnr r,rhr(i)nkrrntr \ l-iccn\c Lns)
<br />-l
<br />amexcmlr utrdcr sc.ri(,
<br />DaIe Own.r.
<br />woRxFqs' c(lNrPiN.sATxlN
<br />DECI.AIAIIIIN
<br />I hercby !filirtr utrdcr r.nrhy of DsNry oft of rhc foUowinr dNlrrarions:
<br />-l
<br />havc md $iilnrninhir r ('cnifinrc or Conscnt k, sclilnsuro nr sorkd \.o rt,cDsllo . is |rrvidcd fdbysc.ri([ 3700.lrlr
<br />f(trrhclrrronto N otrhc lork lnr whichrhc l)crmir i\ isricd
<br />willMinr0in wo,kcr' conlcns.lio. insurumc.,r r.qun.dbySclionlTtx)orrhcbborCodc,lorlhcncrfonmnccof
<br />n isxcd Myworkc .onrnctrrari iNurr.cccrricr fl Inicynu'nbcrarc:
<br />2/i^\z
<br />-lccnilyrhd
<br />ir rhc pcrLrerrccol ihc rork ior whi.hrhi\ pcnnir ( n\u.d.I shrll .tc {loymyNn.n ir anym.rmr
<br />\, as h bc.o,m suhjecr b rhc *orkcr' comFnrarion h*s ofcrrilnmi!. and,rre rhr ill \nourJ hc{om sul,jmi i, rhc
<br />* lkd \ ..nlcn\dion Frvisn'.\ of Sccrion lT0O of rh. l-ahor Cqlc- l +all lon hsirh comply { iih rlD{ pmisn,n\
<br />WARNINC, loibrc lo scurc qo cm'conrFnsarion colro8c i\ unhwtul..nd sh.ll suhj.rl arr cmplot$ ro aimin0lpcMhics otrd
<br />civil lines uD ro om hundRn thouqod doll.s (Sloo.(xx)). in.ddnion
<br />'o
<br />lhc co{ or.omFn\lrion. domlcs as providcd lor th.
<br />Sclion 10',6oflhc Lolir Cod.. inlcrc( ond 0tlomy sfos
<br />Dale: Applimll
<br />| lcF.Nsi-n coNii;aroi
<br />PECIAMIIQN
<br />I hcEby ilfrm undf penalryofFdury rh I ao liened undcr povicion otChaptr 9 (comftring wnh SNrhn 7m0) orDivkion l
<br />or rhc Bxsin.$ and Prorcsions Code, tud nry lic€nsc is in tuU aorcc 0d ef,icl
<br />,,." bl
<br />IB ID
<br />CqNEIAIIIIOIIENDII(C.f,GEIII
<br />I hcrchyafinnunderI'enaltyof!.rjurylhlt rhcrc n ! conslru.tion lcndingsgcncy lor lhc pcrlo mncc ofrhcwork for whichthis [Ernil is
<br />nsucd (Scc.3097, Civ. c.)
<br />ATIUCAILDICLANAUON
<br />I trt b, afid undcr p.!!lr, ol pcrjnry ore ofrhe followinB dshrulions
<br />Ocnnition Pcrmih.Ashcst.s Norificdion Fcdcr0l Rcauhtiofl s (Tillc 40, Pan6)
<br />-Rcq!iFd
<br />ldlcrof l'lorifi carion
<br />rotrsr_!&hnBr({io\r.nxNrlJr tror rpfli.xl,lck)rhrs|r)J.cr
<br />i.ribi ril (arcrhrr rheab.\c irrlb.rnrrion i\com.r ll8rccrocomnlJ_s,irhnllCiryrndCounr,
<br />huiklins connru.lion. !rki hcrchyrurhoizc r.rrc\cntnrnc\ ol'rhis Cirr rtrd C.unry k, cnrcr trFr rhc
<br />u ca0l
<br />u\sg ?4xx drrr[
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Torqueinq
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Sollit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />[/'1eter Release
<br />Rough
<br />Service lvleter
<br />FINAL
<br />Transformers
<br />Sub-Panels
<br />Notes, Remarks, Etc.
<br />I c.,,lq\ AJdrc*. _
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