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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCATATION <br />I hecby amnn undd p6alt! oa p.rjury Ihal I an.rcmpt frem Ih. Coflradou Li..e ljs aor rhc folloNiu .€eo (Sd.7011.5 <br />Busn\6s i Prof6sion Gd.): Any Cily or Couly uhth equt6 a Fynh ro coNlrucl, altd. inprovq doolish or t Pan my <br />sirucrur€. prior Io ils isuarcq also rquird lhc @Dlicer lor sNh rEnnil to frlc a sisncd slalodl lhd h. o. shc is lictrcd ,,uNen <br />k' $. plvisio6 of tt Conlrrclois Liccns€d L.w (Ch.plq 9. Commn.ing wnh Sation 7000 of Division I ofrh. Busin6.dd <br />PmlcssionsCodc)orrhathcorsh€G€xcrtpllhgefron&dlh.b6tsforth.all.8.n€xmplion.AnyriolarionofSdionT0ll5bysny <br />applica forap€flnilsubjdslh. apolica loacililp..alrroanormorelhanfiv.hundrddoll6($500) <br />I. as o$ nd ot lh. !.oFny. o. my cmployd \ ili rv.s6 d rhcir eL .olnPssrion, u'ill do thc wo* dd rhe nru.iu. b ml <br />i, sd.d or orcrcd for elc (Sc.70{4, alsin* 6.d Pbf6sio6 Code llE Contractors Li.as Las doe nol apPly lo d oMd of <br />rh. prepdy $l[ hil.Ls or irIrov6 rh@n. and who lt)6 such \o* hi,ns.lf or h.elf or rhron*h hh or hd os'n mplot6. <br />Drovid.drhar such imp{\@.trls Ec not inloded or ollald ior Bl.. I t ho$66. rh. hoildins ot ihpovddl ir st wnhin on. ys <br />ofcotrpl€1ion. rh. ()$Tq Buildq wil, h,!e $. hrdn ofFovirB thal h. or she did .ol build or iftpm!. fi. pmpsty lor thc pu,pos ol <br />l. s o\ n6 of rlE Drcnqty. an cxrlusivcly conlracxns virh licm.d .odmdou lo consirucl rh. Irej<r (sm 7044. BGinN <br />and ttoicsnnCodc-lhcConracrorsLi(.ns.La\edo6norapplylo osor o i propd y who boilds or impror6 lhdo.. <br />,nd who .onr.L1s for such proiccls $irh a co o!1o(o licsed pmtrer ro $e contraclois l-iccnse t-aw) <br />I ah.\c,nfl llllld sdlioo <br />lvof,aE[s](alr8EBsAlIaN <br />DEC].A8AIIoX <br />I h6.by amnn tr.d6 FRllyotpsjury oac orlhc nnhNins d(ldario.s: <br />Ih.Ledd{illmainroinacdrfitarcolConrros.lllNuFfor(otl6'(orpos.ron.apmUd.dforb\Sc <br />I dry ('odc lo, rhc ndf.mM(. o f !h. NorI lor stich !h. pqnil is isued <br />Xr""*o -',..*, *0116' comp.nsd 'on 'nsuran c.6 r.<luircd by sation lToo of rhc L.ho. cod.. ror the pgfonn ccor <br />rh. Mrk f.-$ hi.h rhiq ffi ,s Lrs.d Mr *0'16' mmlnd'on'rodec. cmft .nd mlic\ numb. e <br />.**€lt-Lqrt- -[rr< A Gsrlr \ J+{- <br />^*,"."i-* Fl A UQ|IS$JE O l e,p*".c'2-21-2D <br />I ccniry thar in th. pqlo@nc. ofrh. rrcrk lor Nhich tnis p.rmil is isu.d- I shrll noi mdoy ry pd$n in ary honcr <br />s d kr tEcom. subjd lo lh. *ork6' compsEation l.ws ol Calilomio. Md a8.€ rhal if I should bcconc subid lo th. <br />\ ort6' onp.@rion pbvisioN oasetnrn l?0{ oflhe kbor Cod., I shall, aonhrvnh comPly lilh lhos prolisioa <br />NARNINC lrailurc to Kue s.rk u .ohp.Nari.n.o . h unla\lul. and sh4l Nbjdt e olFlora lo oilnnd Fuhi6 dd <br />r. one hu.di.d th.us..d dollas l$lotr ofconp.nsalion. damar.s 6 provid.d Lr rhc <br />S<tion 30?6 ofrrELah,rc.dt, inra6l md <br />o"", Q <br />t)t,.( r,{RAll(r\ <br />I hfthy alTm u6de pnalry of Derjury lhal I m limsd und6 povisio. ofChipld 9{commcncins wilh S.clion 7000) ofDivisio.l <br />ol thc Busin* dd P(fsios Cod., ..d hy lko* is in tull lorc€ ad cftdl. <br />,,**".n" ( 2 (l <br />D r: e\ l.-1c-, - Lo <br />\ <br />I hs.by arm uids penally oi pdju r- lhal thr€ is a orotru.lion kndinS ,sac, fot rh. pdlomdce ollh€ erl tu, which lhis Fnil b <br />isu.d (S(.3097, Civ. C.) <br />AITII(ANLDECLAAAIIO! <br />Ihodryarm und€r pmalt, ofpdjury on oflhe followinS delealions: <br />D.molirion Pdmirs-Asbesros Notincnioo Falsel R.rularions (Tillc 40. Pan6) <br />Rcquicd Lato olNolifr caton <br />I cdiry that th. Ld6.1i.lllatioN Elrdin! 6b6los rdnoL al ar€ nol opplicabie lo rhir pmjd. <br />rhar I h.\. read rlris applicalnin dd ro comply\vnh all Ciryud ( ounty <br />f rhis Cny &d Coumy ro al6 upon lh. <br />)or,.At30-D <br />sbovc m ion.d p(!.n, ao <br />Applionr or Ag€nr Sign,tu <br />Site-Work <br />Underground <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Bondinq / Groundinq / UFER <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilinqs (Hard & Soffit Rouoh <br />Ceilings (T-Bar Rough) <br />Meter Release <br />Rough <br />Service Meter I l" <br />FINAL )r//ol t^v o /dy <br />Notes, Remarks, E{c <br />Under Slab / Floor <br />.t la)'1-<\2 <br />_ <br />tl <br />I