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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrehr amrm undd pcn.lry oa pdjory thol I m ermpl lmrn the Cod,adou' t.ic.nse kw for lhc lollowing r.asn (sec.7o.rl 5
<br />Busi.6s sd Piofsion Cod.) Any Ciry o' Couory rvhich r.quns a pdmir Io co6rruc1. alls, im!(x!. & rlish or EPat lny
<br />srrucruc. rr'r to irs t6uancc, aLo r.qrirc thc .ppli.d aor such psmil lo filc a sirn.d sradar lhal hc .r s\e is licd*d p6@nl
<br />ro rhc p.ovisioN of rhc Conrra.loas l,ic.nFd Llw (Chaprd 9. Conm.ncinE Nnh Sdlion T(]OO of Dilisiod I oith. Busrn€s md
<br />Pmtcsions Cod.) or lhal lE or shc is €xenpt lhscnom ed iE basis for rhc all.s€d crdoion Anyviolarionofs.ction 7011.5 byany
<br />applicanl lor n pcnnil subidrs lh. appli.anr ro acivilp.nahyolnol morclhe 6re hundr.d dollm ($500).
<br />l. 6 ownd ollh€ prop€ny, or ny onploy6 \dh s ar6 4 thcit sl. comtssal ion, \ill do th. *oi[ ml rh. slMm b mt
<br />inrod.d o, ollq.d for sL ( Sc 7014, Bosin6 and PmfNions Cod. 'I1l€ Conmdofs Lic.6. llw .106 not lpply lo e ostd ol
<br />rh. pnFdt llr buil& or imp.ov6lh@n. ud s ho do6 such st* him*ll or i6daor th.otrsh his or h.r om.mrloy6,
<br />provided rhal such inptul.ftnls ftnol inr d or oiIa cd for ek. lt k wdd. th. buildinB or imptovchq.n it $ld wilhin on. ,E
<br />olcompl.{iotr rlE Oqntr Builds sill haE lh. bsld of rovins fid h. or sh. dii nol hild o. itwove O. F$p.rty tor lh. purpoe of
<br />r. .soNnrollh€ propdy. an crclusi*l, c.nira.linB Nnn lica*d conrrsclo6to (i*rtud
<br />'lrc
<br />Foid IS( 70d'1. Buins
<br />and ProiBb. ('oder The Conlr.cloas l-icens€ t,aw do6 nor aprlt ro M ownd olproFnyNho builds or improvcs Ihcreon,
<br />and vho conllacls for such Fojds wnh 0 contmdo(s) licffid pu6u r io the Conkacror's Licmsc liw).
<br />I del.np undd Serio. .A & | C. rortl,isrcGon
<br />Dil!: own€r
<br />r(la[E!Ltlco!!ID!-s rIoNDf,gda{ra!
<br />I hcrcby amrin undo p€.alryof pdjury oncolthc follo\ins d(l ationc.
<br />I have and silltui ai,aC.rlincaleofcoN.nlloS€la-lnsurcforwork6.onpouarion,6 Fovidcd for byS(lio.1700 oalh.
<br />tibor Cod., aor thc psfonnancc of thc sodr for {hich rh. pmil i3 issucd
<br />6.^"will rainuin tr on(6 co,bp.N.tion iEurorcc. s Equtcd by Sd io. r 700 of rh€ t bor Codc. lot lh. Fforl@.. of
<br />n G isstrcd My qorkss omposaltun insurd.c .eia md policy nu mb.r 6e.d A-.1
<br />ra.yw-w 7L p€e-AAL Aoz- *or*, 6/rlfz o
<br />I cedify lhal in lhe pdfonnanc. orrhc rvork aor {h,ch rhis r.rmh E issued. I shallnol .nployany pdsan in any m8.n(
<br />$ s to bcco'n. $rbjd ro rh. sorkm' comp.nsal ion lnNs of Califomia, a.d ,sre that iI I shorld bc.omc ubjcd ro rh.
<br />*ork6' .o,np$dion previsio.s of Setioa 1700 oflh. lrbor Code, I !hdl. aonhwnh comply with ll[E provitioN.
<br />\I ININC Failun lo Burc \0r[6' compe]srion colsale is unlarful. tud shall nibj€cl u qploys to qiminal FEhi6 ond
<br />civil fines up ro one hundr.d thouend doll.6 ($100.000). in addnion t. dr.o$ o I co'npcnsal io n. dmas€s d providcd for rhc
<br />s.srion 1076 olrh. Labor Codc. inrsst and arlomey s fs
<br />!tr!L aaulr!
<br />I ncrcby amnn lnder pqalr, or ltriury rhtt lic*.d rndE pmvisn,n orchaprd I (commcins wilh S.ction 7000) of Divisio. l
<br />of lhc Busirsdd ProisionsCod€- md nry licde i\ in lull aorc and efirt.
<br />i3 /e 3g 37.L
<br />?t /z-o ,-*,,*zL"-*!*JJ,r-
<br />CA!flBI]CITANIiEIDINC-^GEICI
<br />I hcEby aitum und6 F.all, oa pojlry lhal th6. is a oislrudion kndi.s ascn , hr th. pnfommc€ ofli€ worL h, whi.h rhb Fmil b
<br />iss,.d (Sd. 109r, Civ. C.)
<br />APPI ICANT DECLARATION
<br />I hdda afnn und€r D.nalty ot psjury onc of llc follo$ io3 ddl&alio6:
<br />D.molnion Psmirs-Asb€sros Notification F.d6al Resularions (Tnb 40. P0n6)
<br />Rcquircd tf,u6 ot Nolification
<br />I cglrryrhar rhc f.de.l r.gtr l.tio 6 r+edinA shGlos rcmoral re nor +pli.ablt ro thi! proja.1.
<br />4b) rhor t hire Ead rhis EDlicaltrn ed sritclhar rh. abv. infomoiion is cord. I o{r* $ comply wnh aU Cilyand Couniy
<br />ordin.ncG and Sr.t. La{s rclnrins to buildins coBttu rion. ed n reb, 0utho,izc rcpr6oktiv6 o arhis Ciry &d Counly lo dl6 upon lh.
<br />rrx\e,nmtoncd F,tcd\ lor hslr...tion N4rx.s
<br /> Dplicunt or aA.ni Signl|trr.3
<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 t_tt
<br />Bonding / Groundinq / UFER aryw titrPt ^t6
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners JV
<br />Roof Top Equipment 7/D/2no \Di/W )4 65
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rough)
<br />Meter Release
<br />Rough
<br />Service lvleter I Ir r/nuna,t ,tfullbl UI Yb
<br />Notes, Remarks, Etc
<br />Transformers
<br />FINAL
<br />,,^,", //.r/-r'
<br />t'
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