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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNAR BUILDl]R DELCARA-I-ION
<br />I her.by aiirm ondd pcflalry of Fjury rhal I m c\dnpl ftom lhc Cott.rcrou Licas. tiw lbt rh. fouo$in8 tNn (Sa 70l I 5
<br />B$in6s atrd Prolsio! Codr): .y Cny or Counly vhich r€qun6 a Fmn to coNlrucl. .lla inprove donolish or rcPan s,
<br />nrucrre Irnr b irs issumce. ale r.qui!6 lhc appli.anr for such pmit lo fiI. a siln d srahd that hc or sh. t lichscd pu6u t
<br />1o rlE pnvttuN ol rhc Conradors Lic€ns.d li$ (ChaprE 9, ( ommcbci.s wirh S<lion 7000 of Division I oalh. Busin.ss ed
<br />PBf.$bns Code) or lhrr h. or shc is ercmpr lhde,iot d rh. bsis lor rhe allelcd cxdnplion. Aov violationolsdrion ?011 5 bv anv
<br />applica.r aor a p.m subjclslhc applic,nlro t.ivilpmahrofnol Dorclhd ar. hundr€ddolla.s(S50o)
<br />L as o$s oflhc rrcpdrr, o ny onploy6 $ith Na!66 thcir sol. cor.posalioi. $ill do ft. Nott sd lheslrud@ h n'r
<br />iolod.d orofrd.d aor eh (S{ 7044- Busin6s dd PrDfsions Code Ih€(onta.rorsLiccNlrsdo6nor.pplvto 0\6oa
<br />Ihc pmpeny who hil& or inDror6 lh@n. od who do6 such !o,l tnnseltor h.ts.llor ttrcush his orhd o\h.tnplov€6.
<br />Eovided lhar such i'nFor@drs mnol i q'&d oroltu rorek.ll hotr66.lhc b{ildi.E or inProYclBt is sJk snhin orc }w
<br />ofcoopL{iotr $. own6 Buildr will hav. thc brdd of prcving lhd hc or sh. did nol build or inFovc thc ,'spsiy for ll"E purrDs ol
<br />l. N oNns o llhc p.opolr, an cx.losivcl, conrrasrios tr irh licscd .ont.do6 lo consrrud rhc Eoj..l (Sd 7014. BuqinN
<br />and lha6i.n ( ode Tnc Conlrackn s L(.s. Law d.6 nol apply k' an .*nd of rrop.n y *ho builds or inpro L 6 lhdsn.
<br />and trho co rads iorsu.h ptuisG silh a Conra.b(, licds.d pnBu.nl lo rheContacrors Licflsc t-aw)
<br />I 0 exenfl udd sdrion
<br />$oRxnRs' contPENSAT|oN
<br />DECI,AA{I{)!
<br />I hs€by sffiirn und.r p.nrll! of psjury ooe ol rh. rolbr ins d..l&.tiom
<br />I ha!€ ad vill @inrain a Cedificar€ of Consd b S.lf-lftur. lor tork6 compsetion. s Fovid.d hr bv scrion 1?00 of lhc
<br />l,bor Code. lor lhc pctomec. of thc vork for $nich lhc D@il il issu.d.
<br />lLI harc aid will nainlaii work6 conpc6aron iGurft., 6 r.qlircd by Sdriotr 3'7oO oalh€ Llbor Cod. for rh. Ffom cc of
<br />thc *ork for *hich $is p.flnn is Ls.d My vort6 compoerion insnrmc. 6id ed policy numbr 4c:
<br />.-,- ,fola P''.rnd -
<br />r"ri., rr".r,., 4 (, \\0\b ,.on*, U4LO
<br />I c.nitylh in lhe Frr.mt.c. of rh.qotk for which thi. pnnir is isu.{.I sh.llnot dnploy tnv l.Mn in ev nmd
<br />$ 6 ro b€rome stjfi lo lh. $ort6' compcmarion Ia$ of Califomia. dd agrd rhat if I should b..om. subi..l to lh.
<br />s!it6' compaerion provisioB olsdioh l?00 of lh. Lobo. Corje, I shrll, fonhw t enply wilh rh.e pmvisions..
<br />W,{RNING: Faihr. tu surc wo 6 conpdMrion covdagc is uilaNtul. ed shall subj€cl an nplo,6 ro ciminrl p€ishi6 dd
<br />c!-il fin6 up (o on. hrn&€d rhorMd dolld ($loo.OOO). in.ddnion lo rhe cosl of conp.Grtion. d.mag6 6 prolidcd fo, $.
<br />S4lion 1076 oarh. t bor Codc inlcr6l ed .tomc, s 16
<br />w", \l?-l Zo u
<br />D!C!,A8AI]o!
<br />I heEby &firm undr pda[y of pdjury rbal I m lictudi undd pmvilion ofciapld I (com mcinS with Sc€lio. ?OO0) 'r Diviri" l
<br />of rh. BGinN d Profsios Cod.. dl ny licd$ is in tuu torc &d clf(l
<br />h to?o\-.)l
<br />,",",\1?-,1@ .",,.".,..
<br />CONSIRUCTION LENNING ACE CTY
<br />I h@by arm und,i p.n,lry of prjury rhd lh6. is a .oislru.1iof, Lndins ssd.y for rh. psfomoc. of th. woik for ehich thit paf,it is
<br />i$u.d (Se. 109?, Civ. C. ).
<br />tando-r \am.
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<br />AFPLICAN'I' DECLARA'NON
<br />I hot!, afrm und( por.lry olp6jry onc of lhc follo*ins deldarioN:
<br />D.molilion PcrDils-AstEslos Nolificarion F.ddal R.8ulations ('l'nk 40, Pd6)
<br />R.quircd Lcrt6 of Noti6crlion
<br />-l
<br />.6riry rhar lh. Ldd.l rcsuhtio6 tsalins sbcros rdo\.1 dc nol appli.abic ro thit poi6l.
<br />I cfiirylhar t hae rcad rhis applicalion dd slrl.lhat lhc aborc infodrlio. i. cotrdt. I asrr to complvvnh.[ citvand counl,
<br />o.dinanc6;d Sur. t?M rcklhs lo buildins coctoclio( ad hd€by aulhoi@ qr6alalive of this Cil, ed Colnlv to dl6 upo. th.
<br />rbore mcnron.d nmrleny lor insp(d)on nurFls/
<br />^pprrAnr
<br />o,
<br />^Bd,
<br />sisn.rur. Yt---fi-'
<br />permr,ee n,ne,prrn,): i.^vltA lxo.lo'vt O
<br />"^,.{LU9
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltase
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rough)
<br />Rough
<br />Service Meter *-z
<br />FINAL tlun)DAo,o sr -p tcl
<br />TINotes, Remarks, Etc
<br />Meter Release
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