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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE rD/srG.COMMENTS OWNI:R BUILDER DEI,CARATION
<br />I h.rcby amm und6 pcnrry oaprjury rhat I or .r.hl)l frern rhc Contraclou Lica* Ls{ ao.lhe follosint .e&. (sd.7oll 5
<br />Busin6s and P.ol6ion Cod€)r Any Cily or County \fikn rcqunB a psnil lo connruc1. .lta. inprove dmolish or (,ait ey
<br />stnElure ,,ior lo irs nsudcc. also r.qut6 lhc lp,licant for su.h Fmil to lilc a sisn.d sraronmt lhal h. or sh. b lics.d puB&l
<br />b rh. proririoG ofth. coolracror's Liccnsd ljN (Ch.pts 9. CoD,nmcins trilh S.clion 7000 ofDivisio. 1 ofrhc Busirc md
<br />l,rufsions Cod€) or lh.t hcorsh€ is€rolpr lhscliom &d rh€ bssis ror lhc all.B.d.rdflion Any liolarion ofsclion 7011 5byany
<br />aptlica nn a p.mir 3ubjda rhe aptlicom to r civil p.n.hy o f f,or mordhan fi\ e h!o.t.d dollm ($500).
<br />I, ar o\ncr or the ForEny, or my mploy6 wilh * a!6 6 $eir sole co p*ation. Nill do th€ qork and tfie slruclrc is ml
<br />inrmd.d or oifer.d lor sal.lS(.7044, ausinds Md Pro tNbns Codc t h€ Conlraclois l-i.flsc Irw do6 not aptly to d o*.d of
<br />rlr tmrdy who build! or thlmla rh@n. md *lkr &16 $ch $trk hnns.llor h.6claor rhrourh his or lEr o{n.'nploy6.
<br />prolided rhqr such i'.pNvdqls @nor int6& orofisql forele lf, hoRdd. lh. bnildnl! or improv.lffir is eld silhinone y@
<br />ofcohpldion. thc Ownd Buildo $ill har€ tfie burdo ol provins rhal bc or she did not huild or idprov. rhc tropdy aor fi€ purFs of
<br />l. 6 o$n.r olrhc Fopaly. dn qclsidy conrr&1ing *nh Lcred co.tBcloB ro co.slrud lh. pmjd (Sc 7o1t. aNn6
<br />and ftofBsn Codc Th. Co.rracroas l-ic.n.c L6s do6 nor lpply lo e o*nd .f propdy wto builds or improvA lhqofl,
<br />and *ho o.lmcls for such Foj..rs wilh. codmclo(s) licm$d pusu r to tt.conrracloas l-ic4. t $J.
<br />I 0n .r.,npl ondd sdion
<br />uaaxE8!:l9uEExs4!(N
<br />I,IECIAEAIION
<br />I h6eby amnn undcr pc"ahyofpsjuryoneoflhe lollorvinr dtrlarations
<br />I h.v.md willr6im.in acdificd. olcon*.r ro S.l nsnrc ior workd- compasotion. a prlvid.d ior by Sction 1700 of th.
<br />l-abor Code. for the pdlomace onhc so't for ohich rh€ ,orir is isucd
<br />I h.!. and will ,nai.rai. $ ort6 comp.Nario. iNomnc.. s r.quied by Selion 1700 of lhc Libor Code, for lhc pElomdcc of
<br />th. worl for which thi! pdnn is issu.d. My work6 compdMlion insumce cmis &d policy nobd &c:
<br />c.,,t,, r Atfk a../)aqt;<-fiat)
<br />1*.\ n,ba - 7y9Lz$tft@a
<br />I c€nify lhal in lhc p.rfomancc oflh. *ork aor shich rhis rEmil is i$ued.I shallnot mplo) ant p(s. i. ahy m nd
<br />s, nr b becoEe subj{r lo rh. $.*6' .omp.nsarion hss of Caliaomi& ed aBc rhar if I should becomc slbjdr to rh€
<br />worl6 compcBalion roviiions of S$rion lT0o ofrhr bhJr Cod.,l sh.ll. ionhwith comply vilh lhos provisions..
<br />WARNINC l'.ilu.e io Kue rorleB conrpcnsfllion cover.s€
<br />cL'l fincs up r^ nre hundr.d lhousd '.to'la^ rirot.,\'u). I
<br />Seclion 1076 oflhc l,horCodc. inlf6t aDd axom.y s ts
<br />m o plt)\.r ti rinin.lliral(
<br />I hmby amrn rndd p.nalry of psjury rhd I
<br />.I rh.BusinBsud proaRrioLr Codc. Md
<br />oachapts9(&m ErinxsnhScclio.700q)oaDivB$nI
<br />I h€rcby afim unds !.nalty of Ddury thal Ih6c is a
<br />issu.d (sr 1097.ci!, C ).
<br />Ir.d6 s N.o€:
<br />lor rhe polomdcc olrh. qork aor which this pqnril is
<br />AISUCANLAECI,AsAI,Iq!
<br />I @, .frn uid6 !.nal', of pdjlry onc of thc following ddl@rion5:
<br />Dc'nohion Pmns-Asb.slos Norification F.d@l Reulations (Tnlc 40, P6n6)
<br />Rcqut ! lrrrd oiNorincaion
<br />I cslify that rhc f€dcral resu ld ions reB{dins dbcsros rmovaltre nor a$,licable 16 rhis pmj(t
<br />l( l!c1'tr rhr llu\crcJJ rh rim tr.rt.rJinatu!rintl shrc L.{3ftbrinr 'o bui
<br />.l$. nrmtun€d pnipcn) lir iBperion
<br />r. cornply s irh all Ciryan.l Counrv
<br />oirhisCity d Counryro dr6uponrhe
<br />\IIlicrnl o, ,lxol Si!trrrnr.
<br />P€m'ilft ncne(p.inl): K L57n-""," ,rz/7/t'/
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rough
<br />Ceilings (T-Bar Rough)
<br />I
<br />Rough lilttlll >ttlV"L +ry | - DElv1DU$rt,trG
<br />Service Meter I
<br />FINAL lzl,tl(1 btpoqv.b11
<br />Notes, Remarks, Etc.
<br />",r",, tZl4t?
<br />,**..*.. 2
<br />"". , tzl jfr 7
<br />Meter Release
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