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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNI'R BUILDIiR DELCARATION
<br />I hd.i,, amnn under pcflalty ol p.rjury th.r I on cx€nDt from rh.-Contr.,r6' LicrN tis lor the follo\viu !.en (Sd.703 I t
<br />Buins s.d !rcf*ion Codc) Aoy Cily or county (hict r.qote . Fflnil ro .onshrl. ah6, nnprolc dmolish er r.,an my
<br />srrucru. pri6r ro ns isud.e. .lso rcqutB lhc applic.nt for su.h D.mil to file a sryncd $almdl rhar h. or shc is licdscd PUEWI
<br />to thc provisioas oilhc Co.rdcroas Liccni.d La* ((rEfld 9, aommemirS wirt Sdion 7000 ofDiv$ion I .fthe Busincss md
<br />Prcresions Code) or thal h. o. sh. i!.rmrl thd.fiorn and th.bsk aor the allcs.d cxdprion AnyviolalionofSelion ?011.5 by any
<br />.pplic6 aorapcmritsubjdslhc.pplicantloacililpcnaltyot.olhor.rh&fivehrdreddouas($500)
<br />L 6 osner of$. pop.dy, or b), enrplole Nirt v.B6 slh€ir solc cohp..eri.n, *ill do rhe so and lhc nndr 5 mt
<br />idede{ o.olIred aor elc(Se704.1. Busin* &d &'or6s 6 C.d.: rh. a'ontradois l,ictrc L,ry do6 not applt ro .n o$nd o t
<br />thc p'lpqly uho l,ril& or impov6 thqotr. d who &6such \u,* hnnsclfot hdklfor throlsh his or h.r o(r..'Ployc6,
<br />ptuvid.d thot sNh imlnovendls e rcl iordd.d or ollecd lor s!]e Il ho\'r"d. fi€ buildins or impovffil is $ld wnhi. o.. ,d
<br />olcompkion. rh. O*ncr Buil&r rill hale tc hnd.n ofprolin8 lh,l h€ or lhc did mt bulld or inNv. fit Pspdl, for lhc plrPor of
<br />L s omrs oi lhc prop6ry, on cr.lusir.ly .ontacr in8 Nirh licors€d conlrNtoFto col(rud rhc rojd (se 7orr. t,llirs
<br />dd P$asi)n c.dc: Thc Conlraclors Liccnse Law do6 nol a$,ly m d o$.6 orprop.rly who builds or inprov6lhdd...
<br />and *ho conrmcls for such troj*rs *nh a conta.to(t li.fted puBud rolheConl,rtois l,ictuc Lr*)
<br />I dn e\.mpt undcr S..lion , B & P C. for rhis r6on
<br />uaf,tr!8s:ca!!f,Els rar
<br />DECLAAAIIO!
<br />I h.reby amun unds pc0alry oI psjury on€ otlhc rolloyins d(leario6:
<br />I ha\ . dd {ill mainrain a C.nificalc oi CoMt to sclf lNurc for *orkm .onpdB.lio". s pro}ided lor by sdion 1700 of rhc
<br />l*bor Codc, ld lh. polomdrc o arhc worl for which lhc pqnrit is issu.d.
<br />Ih0ueandLeiU'nointaioreorldcomp.sarioniBuiafte.srcqunedbySdionlT0(rorlhcl-^b.t(bd..lorlh.IErlonn&..of
<br />rlt work lor\rhich thls pqril is $uo] My *oik ,T +t4rd
<br />caricr and policy nufrb.r
<br />259c4,a-CNW /L,r"r*r.*,3 L)8_6_?:t el
<br />lccniayrharinrh.pdfolmnc.oflh€$orkfor\hi.hthisp.rrnilisitsud.lshallnorsDplot.ntpssonioaoydrnnd
<br />s 6 io b€conrc Nbjdl lo r hc Lvo*6' c.m!i.n$r ion l.\rs of ( alifomi.. 6d asrd lhal if I should hc.ome $bjd to the
<br />\rorkql compeNlion prolisionsolSdrioi 1700 ofrh. Latir Cod..lshall,lonhwnh comDly Nirhlho$ tro!isio6.
<br />sdure \ork€rs' compcNalion co\cralc E unl vlul
<br />r r€d thous d dolla6 ($100,000). in addnbn ro
<br />d shall subjc.l s onploys lo o,ninal p.nahi6 ..d
<br />ol coflrpcNlioo. d&n.sd a provided aor rhe
<br />Cod€. inr.rst Md atom*t a6bZO
<br />!IC!.!8.!-! !!rf
<br />I hs€by anun under p.nax, o apaju, that I an licflsl trndd provision ofchafld 9 (commmcints $ilh S6tion 7000) orDirision l
<br />of thc glsios ed P(l6ionr cod.. .Id my li.6r is in fuU lora ud .rtur
<br />,z>)LicmcclN ,
<br />-.-
<br />"^," o, f t>f za>-""*..4
<br />I hcrcb! allifln trndd t)erit! of pcrru' r- ltal dr6e E a.o sl4.ri.n Ldding.Scncy for lhe pgiomoce orlh. \rorl for $ni.h rhi! tsnri b
<br />is$cJ is.( 10q7. ciY c )
<br />Lcnddl Narne:
<br />AITLTCANLDIiCIAB4IIO!
<br />I had, alljm undd Fnalty oflojuryon€ oflh. fouowing d(ldlioc:
<br />D.dolition Pmire^sberos Nolin.aliotr F.dml R€xulatio6 (Till. 40. Pan6 )
<br />_ Rcqun.d Ldl.r oaNolificalion
<br />I csrily rhar li€ f.d6al EEul.rioG rcgading 6b6ros rmolal e. nor aiplicabl. lo lhis prcjc.lx
<br />I ftd,L rhar I ha\ c 'ad rhs .pplicst mn dd $dc rhd rh. .bo!. inlomalion t con61 I aBra ro .o,nply wnh .ll Cily and Counly
<br />odioanc6 dd sralc las rclar ina lo buildin! conn d\i hercb) aurhoriz. itlrLscnhns.lrhis Cn,
<br />ats\ c nBtrlioned popcn) nr
<br />Appricrnlor ,\BenlsknNlure ;A/;A
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />[Jnder Slab / Floor I I
<br />Bonding / Grounding / UFER Dll+fia i 5'7
<br />Transformers lr
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment Zo 1>lrmat .#t 7
<br />Factory Wired Unit 'ut
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rough
<br />Ceilings (T-Bar Rouqh)
<br />Meter Release 2 ?o Dftnr)a -f t-/
<br />I 0r
<br />Rough
<br />Service Meter
<br />FINAL 7 D
<br />Notes Remarks, Etc
<br />Ldd6 s ddrss:
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