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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUII,DER DELCARATTON <br />I hcrcby otfinn uMcr pcmlty ol pcrjury th.r I m crc'n/ nonr rhc Co ractoK Liccns tiw r'or rhc tollouitrB rco$n lscc.703l5 <br />Busincs ond Prcfc$ion Codc): Any City or County which rcquncs s lcmil lo anslruct. alrcr inprovc. don,liqh ,tr rcj,Jn Jny <br />\locrlrc. orlo irs hslrnce. aho r€qlnes lhc amltanr for suchternir ro file a signcd {d.n$r lhdl tr.r shc iq li.cn*d puNunnl <br />Io rhc Frolis$ns or rhe conlE.loas Liccnscd Lrw (Ch.rrcr 9. commncrg wilh Scclion 71xjl] ol'Dilision 3 ofrhc B rinc$ !!d <br />Pror'csions Codc) .r lhrt heorshc hercnrfl lherclionrand lhc bnsis lbr the llh8cd crcmprin Any li.lrrioh.rs..rion70ll.5 by,try <br />imlic.nr foi n lcnnir subjNrlrhc rppli.anrlo..ivilr.iahyofnot r.Bthan l,vc hundr.dd.llo( (S50Ol. <br />-l- <br />as owrc, oilhe nmpcrry. ormyemplorles wirh $rges os rhcir elc corlpcnsarn,n. will do rlF w..k dd rhc qMrut is not <br />imcn kd or otr.rcd f(tr sl. (se.70d4. Brsincs and Pn,fcsbns C.d.: Th. Conra.roas Licc.sc tiw docs nor apply nr on osncrof <br />rhc Impcny wh. lloildr o. inrrrorq rltK)n. aDd who dm $ch mri hinscll or hcr*lf or rhR,ugh hi\ or hcr own . rrbyccs. <br />pr.vidcd rhd such inuovcnr.h arc mr inretrdcd or ofcto'd for eh ll ho*cvcr rlE nuidin8 o. inlmvemnl t $ld wirhinotu rtu <br />ofcorylcrion- rh. Osncr Buiklcr sill hnvu rh bud.n ofl,olii8 rlEr hc or sh. dil mt build or irptuvc 0r pRrFny ior lht purlnE ol <br />I. o*n& ol rhc prcpdy, , cxclulivclt conta.ring $irh li.cn*d conk(ttrs ro .o.{ocr rh- proltrr (scc 7(}4-1. Bu\in.\\ <br />rRl th,ftsbn Conc ThcContact, \ l-i.cnsc l-aw docs nolapplyh ano*ncrofli(T.ny wh. huildror rmrrovcs rhctcon- <br />rnd who ontrucr r'or such pojccls wnh o Contndo(n ltctr*d pnnu0n o ihc Conrracroi\ LEcn\.ljs) <br />-l <br />ircxcnu u cr Sccrn r <br />EOAtrE&LIIJIIIENSAI]ON <br />DEIIANAIIO! <br />I hcrcbi afi.nrndcr I( rlrvoftcrlu.y. c . r rltr ln Lk)*i'rg dcchrutoi\ <br />-l <br />havc nn willrointri. a Ccniicatc orConr.r to Sclf'lnsurc ior workss conDcnsarion- a\ providcd rnr hysc.rion l7(n orrhc <br />tib()r Clilr. for lhc ldfolrmc of lhc *ort for shkn rh. ,.rmn n issud <br />-l <br />hou oml w ill ,.ainloin *o*cni conl|rnsarion in\uEmc- as rcquircd by SErn,n l7fir or rh. ljlxtr C.dc, ror rhc nctfonmncc .l <br />rhc w.rk fttr*hichrht pc,mir is h\u.d Mrwo,ksi compensalion insurMc cnrif ar'd rslicy nrnb.i tc: <br />I c.niay rhar in rhc p.raor@md.frh. sork fir which rhis pcrmir is hsu.d.l \halltror crployatry pcro inant mlnncr <br />$ Nrohccom subj.rr ro rhc strk€^' conDcns,lion hwsofcslirornia. ond ryNlhol iilshould ti{onE slhJ.rl ro rh. <br />*otkcrJ ompcnsor ion pmvniom ol Sdion l7m of rh. tjhor Codc. I shall- fonnwilh conuly wirh rh,s rrovi3ions <br />WARNINCT Failurc b su'c uoi*6 snDrnrarion c6!dn8. i\ u.lawtul, and shall subj.rr .n onploycr ro riminal rEmlri\ d <br />.i!il fircr u! b otrc trndr.rl ihdrs,nd dollarr (Sl(r)-(xl())- in ddnion k, rhd co{ orcon!.nerion. d.m8.s rs lmracd aor lhc <br />sccri.n :ll)76.frhe ljtnr C.dc- i crc{ lnd nnomr\ frcs <br />LI!:ENSEDJANIBACII)a <br />DE!]I,AXAIIoN <br />I h.rcby arnrn undcr p.ahyoap.rjuryrhar I rm liftnld under rsvirhn or ch.pt.r 9 (ommrcin8 Bilh Sccrion 7000).fDivnion l <br />of lhe BlsnE$ !.d Pnfessions Codc, a.d my ltens t in frrll forc and .ff<r <br />CONiIBI]CIIONIENIIICJ lI <br />I hcrcby Nlttrn undcr F.rlly ol pcrjury dar lhcrc n ! consfl.rbn L.din8 .Ecncy for the rErformrc of rhc lork fr which rhh Fhir i{ <br />hsuLt (s.c.1097, Civ C) <br />AIPI,ICAILIIECITIXAIIAN <br />I tErhy,trm hddr pci.hy or pcrjury oft or rh. folldwins dcclar,' i.ns <br />Dcmlirion Pcrmih Ashesros Norificarion Fed€ral Rqllarions (Tirlc40. Pan6) <br />-Rcqun€d <br />L€lrerof NotilEarion <br />I crnify rhnt rhc lcJ.rrl,cguhrons rc8rdiDsxsb.no\ rrnnr'rlrc or rmh.rhlc krrlN lR)j..i <br />-l <br />ccnilyrhrt I hNc rcadrhh0fplic ion aM srrtc rhnr rhc at vc irfonMrion h corccr IaExeroconrdysirhallcnynndcoufry <br />odin,Rcs and Slat. tiws rcLlirl8 lo buildina .onsrrucliotr ond hcrchy0urholnc represcnRnes olrih Ciry and Cornryro.nrcr qhn rhc <br />rbvc nxDli.md propcnt rorinsFrli purFscs. <br />Ap!,,i(a o.Aa0lSirnnlur€ <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Si gns (monument) <br />Lile Safety /Low Voltaqe <br />Fire Alarm i Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bondin g/Grounding/UFER 7/q/tx tDrr( <br />Transformers u <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Rool Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilings (Hard & Soflit Rouoh <br />Ceilings (T-Bar Rouoh) <br />Ivleter Release VUIC ,\\-frZ <br />.-/+174 TQI ss z-t\ tf( <br />Rough - <br />FINAL T/{-4/ts c-l\ <c( <br />Notes Remarks, Etc <br />Service lvleter <br />tt