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ELECTRICAL-INSPECTOR RECORD
<br />O\YNER BUILDER DELCARATION
<br />I hneby .016 u.dd pcnali, ol pdjury 0',l I cxmp( hn rh. Conhdo^' LicG tiw for lh. aouoeins rcNr tsx 1n] L5
<br />Businds 3nd Prof*ion Codc): A.y Cily or Cou , which r€qut6 a p6rnn lo connrud, !lls. irprov€, donolish or Epatr 4y
<br />srrudurc, rrior ro irs srudce. also rcquir6 rhc applic&t fo. such Fmi to lil. 3 siSn d slalmal thrt hc o! sh. b licmsd pusumr
<br />ro th. FovieioB of $e Co.lra.lors Lic.,s.n Liw (cnagd 9, Comncncins with Sation 7000 of Division I ollhc Bsin.s ed
<br />Prcfsions Cod.) or thar h. o! snc is (cmpl thqciion od thc bsis lor $c all.s.d cxd0ion. An, liolalion of s<rio. 7011 5 by e,
<br />lppltoi aor 6 p6ni subjGu the rpplicdr ro r civil p..ahy ol nor Dore tlr fiv. fiutrdr€n dolles ($t00)
<br />.1, s ownd olrhc popcny. or rny ctoplo)s wilh {ag6 6 rheir elc conpnsdion, wil & lh. woi{ ed th€ nrudu€ is nol
<br />i 6dcd or ollded for elc (5*.?044, Ausin6s ed P.ol6sio.s ( od.: Th. conlraclols Licm lne do6 nol aply to M oM6 oa
<br />theI,D!6ry who bilds or ihpro!6 rhd6q and s,bo do6 such srk hiis.lf or h.*lf or ihmlAh his ot hd own cf,plorrB.
<br />provid.n lh.r such improvoMls e mt inro&d or ofts.d for ele li hosdq, rh. buildiry or inprovdmr b $Li wnhin on. ,a
<br />of coBplction, rhc o\Itrd Build6 vill hr{ th! hndo oatovinS rhd h. or sh. dil mt toild or i,qovc ln. pDFty lor lh. prpG€ ot
<br />l, 6 ows olthc Ilropsry. mexclusivcly contEcrins wirh licc6rd .oitad66 ro codttud rh. FojN (s€c. 7044. BusinN
<br />d Phrsion Codc: Th. Coma.ror's l-io.ns. Law do6 nor 4plrro d o*no ofpropdy vho builds or nnprovG th66n.
<br />and who contmcrs lor such prcjccls wirh a Coarado(,licmsd pu6u tiorhcCo rador'rLicm.Ijw)
<br />-l
<br />m.x€npl utrds S6lion-. B. & P.C. forlhts r.&n.
<br />tloBK![t_coMPratallaN
<br />DECIdAAIIO!
<br />I hd.by afiim und.r Fdty 6i p-jury otu orrh. lollowin8 deldarioGl
<br />I have d willnunnlin a Ce.lifical€ oicotror to Scl nrur. aor rvorke compoMion. a prolidGl lor by Salion 1700 oafi.
<br />l,abor Cod€. fqlhe prrom ccoflhcwo* aor q'hich lh€ p.rn( G issu.d
<br />-l
<br />ha\ c &d u ill ,nainmin { 0116 cotuposarion itrurec.. s r.qun€d by S€clion 1700 ollhc L!b., Code, lor lhc pofomdc. of
<br />\fi. \rcrk lo! uhrch rh6 pmir is irsu.d. Mr trorlm' compGrron Nurrcc cm'o aid rEl() nrmbo m
<br />)opa ,o t)F;rc lPst,rc.+.,cC (ar../
<br />toztq+{abT
<br />t ccniry lhal in lhe psfo,mac€ ofth€ pork for *hichlhis p6nn is i$uol, I shall not mplot ony paso. in any mMn r
<br />$ 6 lo bdo@ slbj(l ro ihc Mrk6' comp.nsrio. laws o f Califomia, ed asr thar if I should bcomc subjrl lo thc
<br />"ort6 onpq$l ion pmvisioN of Salion 1700 oilhc L,b.r Cod.. I shall. aonhwilh compl, sih tnos ptovisioN..
<br />!|ARNINC: f-ailur€ ro su€ Nork6 comp€Mrioo cov@sc is unlastul, ad shall subjdt o onployd lo diminal !.ndhi6 Md
<br />civil nn€s up lo onc huldred thoumd dollus ($l in add(io. ro rrc.ost oacomp.Narion, dunag.s a provdcd for rhc
<br />"",",
<br />r/iq lloao A 0
<br />I hftbt rmrm unds lrn.liyolpcrjury rnar I m licss.d provsion of Chapt6 9 (cooncn.ins wnh Sdlion 7000) olDivisi.n l
<br />ol rhe Ausn6s md ltolsiore Cod., and my licas is in lnll lorce ad .fic1.
<br />B 1(C.o(
<br />I h@by a,Imn undd F.ally of psjury lhal
<br />i$md (sa. 3097, Civ. C.)
<br />Ladd s Nmc:
<br />I€nding aBdcy f6r rh. Ffomd.c oafic wort tur whi.h rhi, pqnh n
<br />ASTLICANLDECIAAAIIQ!
<br />I hdtby arm undd pciahy ol psjlry onc oflh. followins d(hialioa:
<br />o.molition Pmils-Asb61@ Notiicarion F.d.rd R.gxlariofl s (Tnk 40, Pan6)
<br />R.quircd L.tlB of Noiificalio{
<br />I cdiry rhat &c lldqal r€gu lat ions csddinr 6b6los rdoval & not arpli.ablc to dis pNjec'.
<br />red rhis application dd strle lhar rh. abovc infomarion is cotr(r I agc lo coq)I, wilh al Cn, and Cou.ry
<br />Laws Elaiis lo buildins coistruclion. dd hdeby ,ulhorn rcprGmlativ6 oafiis Cily d Counly to olq upon lhc
<br />Uri \\ i
<br />APPROVALS DATE ID/SIG.COMMENTS
<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 />Building
<br />Under Slab / Floor
<br />Bondinq i Groundinq i UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls Rou h
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilings (T-Bar RouOh)
<br />Meter Release
<br />I I LL r-4
<br />Rough Lltv LU .l,Ar '\Yd ((L4O /
<br />Service Meter I I
<br />v
<br />FINAL 7t rL *6-/
<br />Notes, Remarks, Etc I
<br />'\ll-
<br />Rev.0B-07-2015
<br />C^ t^.\
<br />t l ,qla(JC
<br />Site-Work
<br />Communications Cable
<br />Air Conditioners
<br />'l'', /L,tn t ttc Q. ,b--.-J
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