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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION
<br />I hdcb, rllrm under paalty ol pdjury thal I m €rcmrl from rh€ ( o.rado6 Li.@ tnu lor lh. lollo{ ins rcen (5{ 701 1 5.
<br />Busin6s d Prof6ion Cod.): Any C y ot Cou.ry rvhi.h rcquircs a tEnit lo conslrucl, alls, improv.. danolish or rePat uy
<br />srrucrur.. pmr to ils i$uan.., d$ reqric rhc applicaar fo, such p€mil lo filc a st.cd srarmd Ihd hc or slE is licqsd plls@l
<br />to lh. Fovisions ol th. Conrracrois l.icded La* lchalrd 9. comm€ncinB $ilh S(tion 7000 of Dilision I oflh. uxsinN md.
<br />Pref.$ionsCodc)orrharh..rsn is.rdnpl lhrelroD and rhc hsis lorlh.allcled donFi.n. Anyviol.lio.olscctFn7011.5bya.y
<br />appli.mr for a pnnn subjets lh€ .pplica lo acivilpcnahyoanor norcrhan fiu hundrcddollds($500).
<br />l. 6 oMer of rh. ropalt, or nt mploye rvilh $as6 s th.t ml€ com!.@' ion. will do lhe $rk dd llE slnr.r@ is mr
<br />iflralded or oftftd for $lc (Sc.7044, Busins ed P6ldrtu6 Cod. Th. contractois l,ictrc Irw do6 nor a!pl, lo an own6 ol
<br />lhc FDrEny *ho buikts or inpov6 @n. ad * ho do6 sch \ o* hirE.lf oi nas.lf or Ihmulh his or ho oM dploye6.
<br />prcvid.nrn sucn iBpmlqndts &.R, i dd.J orofid.d for sL rf, ho$*.6.|hl buikitrU ot i,nprcvmdr is$ld uilhinon€ )@
<br />of.o,nplclio.. lh. (xnd Bxildr will hrve lhc bordd olprorias lhd hc or shc did nor bdld or irnprov€ lh€ p{opdy lor lh. puroe of
<br />l. 6 oNncr of rfie Fopeny, dn erclusncly .onta.ring wnh licmscd conn actoN to co {rud rh. prejd lSG. 7044. lrsms
<br />,nd l\rif6bn cod. Thc Co.kaclo.s Liccnse LaN do6 nor Eprly b o oq nd of p.op.ny s ho buildr or idpro\.s rhdon,
<br />a.d qho conllacc ror such p('jc.l. lvirh a ( ontmdon,licms€d pursua io thcConkador's Li.6& tiN)
<br />I dn.x€no u s Sslioo I &P( fdrhisleasoo.
<br />WORKTRS' COiIPENSATION
<br />OEQdAAIION
<br />I hcrcby amrm unda pmally oapdjury onc oarh. follosi.8 d4ld.tiom
<br />I hovc dd Nill nEinlain a Cdificar. o f Co.sl ro s.lalNur. for work6 comr....rioh. a prolid.d for by Sdlion 3?00 o llhc
<br />-\-l,bur i ^de lor rh. psfonnmc. o I lhc so* fo' $n'(h,h. pmir u isl.d
<br />d
<br />i|- I ha\ c and *r ll ma'ira. " o G' comp.Bot ion Nuranc.. s rcqutcd by Sdion I7oo ofln tjbor Cod., ior fic pcfoDdc. of
<br />Nhi.hrhisl].nn t isstri{ M) $orkos lonrpesalnrn insuraN e .tmd dmlic\ numbs &.
<br />-J,eS\aq
<br />0",,.,^,.*,.'LLlSlE]fo3Jgl !+6 Expnes A'-l'Z.r
<br />l.dlily rld h lhe pertormtrncc ofrhe *olk for whi.h rh's p.rfrn is issuLi. I slrllnol mployany Pr$n in tny mannd
<br />F 6ro h.co'nc subjtrt ro rh. $ort6 .ofrFnerion l.wsof( alifomia. and agrc rhd ifl should b..omc subjet io th€ t$o.t6J co'np@rrio.p(vniotrofs.rlion 1700ollh€ Labor (rrde.I slEll n,1h\ h cohtly $ ifi lho* pmvtioni
<br />wARNlNc ljaihr. lo Kur. sorkss' compsNrli{,n corsase rs trnl.$lul. aM slEll subjed an snplo)d ro on nal ,cn0lti6 and
<br />.ivil lin.s np ro onc hundled thouend dollm ($100,000), in irion kJ rltr cosi ol.onrpcNal ion. dd,as6 a Uovid.d for Ih.
<br />s*ion 1076 olrher-abor(orlc. inr66r and alr
<br />t)r._( t.rR.\t IoN
<br />I h6.by afilm !.d6 poalry of psjory lh,I I m liccs€d nndd provl,ion ofchafld 9 (commd.inB silh Sation 7000) of Divisioo l
<br />ol lhc AusinN Md Prcfsioo Codq ed my li..M b in aull fnce md c,I(r.
<br />B Ll1z5E1
<br />o",., - t -Q-a
<br />LQrltBr!rjoN-.taulr!_llqr1!
<br />I nftby altrn uf,dE p€nahy ol p{jury lhal th@ G a ongtudkrn k di.g rgdcy for th. pdfomdc. oilhc vorl for wlich lhis ld'sil i3
<br />b$.d (Sd.309?, Civ. C.)
<br />AITIICANLPETIAAAI]A!
<br />I ludr, aitir trnd.r !sm[y olndjury on€ ollhc lolloNiry ddlaanonq:
<br />Dcm.liiion Pmirs-Asbrsros Notificarion Fcd6al Re8ul tuns(litle l(r. Pano)
<br />R.+ircd t ir6 of Nolilicltion
<br />>[2 ] .ori.y rhur rl," r.ddal rclul.rioro Egdding sbGros r6no$r @ nor applicabl. ro rhis prcjdr
<br />k *::l*tl;I have read (his appli.alion md e.lcrhar dr€ ahve iolormalion is corect I Egr6to complywilfi allCnydd Cou.ry
<br />i!6 of rhis Cny ed Cou.ry lo dle uFn tk-*,. t- f-2--alFv. rnotioncd ptoD.n, for
<br />Aruli(rnl or ,\Eeni Sknr
<br />\tCrrar'.e\-\.2
<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 />Building
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment ri
<br />Factory Wired Unit I /n
<br />Walls (Conduit)I \3 )',1)\Yr,ut.O.(1,)(N
<br />Ceilin S Hard & Soffit Rou h wffi /i.
<br />K\i
<br />Ivleter Release
<br />Rouqh
<br />Service Meter I I It //WW 6U
<br />Notes, Remarks, Etc tl
<br />Communications Cable
<br />Walls (Rouqh). t ,l
<br />\
<br />Ceilinqs (T-Bar Rouoh)
<br />FINAL w
<br />,,,.- \- "t-)et
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