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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE IDiSIG.COMMENTS
<br />I.* wNr ol ihc FmFnr, or Dry crnplolccs pilh wlgcs as rhcn sob conr{n\ari{nr. will du rlf wolk ndcsltrrwisml
<br />inEncd or ofitrcd lor $lc (Sa 7(!4. Busincs and Pror'cssions Cndc Thc conit0.ttr s Li(n{ L.w docs nor lpply t' an osn r or
<br />lh. !6Fny wh. build{ or inpo6'tEmn..rn who docs suh wo.k himscllor hcrcllor rhrough his orh.rown cntl.yccs.
<br />povidcd rhar nrch irworcmnh -c rn inreftH or ofi...rl ntr qt lt k,wcrcr, rh. t^rilline .r in{m\tmd t sld wilhin oR )ts
<br />ofconl)ldioo. lhc Ouncr Blildcr will h!rc rhe ttrdcn of Fovins 'hd
<br />hc or shr dil nor build or inpn'vc rhc ,mFny fot rbe I)rqF$ ot
<br />Dor.: Ouer:
<br />WORXFRS' CONIPiN.ATX}N
<br />DEILAIAfION
<br />I hcrchy Dffinn undcr pcnalryoipcrjury onc oilhc tolloqing dccluralio.s:
<br />I hrvc ul will nrinriin r Ccn irt.rc of Conscnt h Sclf-lnnrE lor $orkcr' co'npcns ion. as fo dM ror hy Sel ion :1700 ol lhc
<br />Lltxn Codc. rorrhe F.tomn{ oi$c wort for which thc,,.rm ni$ucd.
<br />I havcand will mi a itr worksr conrcnslr i,nr insu.oncc. as rcqtrncd by sLt' ion lTtx) ol rh. Ijt'o! Codc. lor rhc Ftfomtu. or
<br />rhcqorktorqhichrhh!.nnilisissu.{Myworkcr\co'lpcnslrn,trin\urrncc.rnicr xl poli.y trunrber nrc:
<br />Poli.yNtrmhrr-tlxtircs:
<br />-lccniry
<br />rhrr in rhr p.nanmfl.c olrh. work for shich rhis tcrnrir i\ nrucd. I shall nor tmnk,y rny P.rcn nr any nrnncr
<br />s *lottmnr subj.rl roihc $orkcs comFnsalion hw\ofcalifornir. d ag rhar ifl should lE.oN sub]cd t,rhc
<br />w.*.n.o.rp.nuri.ntmvkionsofScctionlT00ofrhel.fitrCodc.lshrll,fodh*irh.ontlywirtrhospmvhions
<br />r .trlnor.r n) di'niml |*mti$ ind
<br />\rrnn,. da rrc\ a! tn,v cd lnr rhcc,vil nnc\unh.Nhu ir.d rhor\rn,i dollrs (!10O.0(lO), nr Mdfidr !)
<br />Sccrion:1076 olrhc ltrtxtrCodc, inrcrcn rrd onry\ lcc
<br />DECI R,TTION
<br />I h.rcby.ffiin undcr Fnah, ol,'.rjury rhlr I am liccn*n lndcr rrvhion olCh.plcr 9 (mmmminB til! Sdrbn 70m) olDrhion l
<br />or lhc a,sincs ud Pior.sions Code. ard myliccnsc h ir tull fore a.d ctfccr
<br />CAIiIBI]gUQNIENDINCIGENCI.
<br />I hceby alfrm u.dq Fnllty of F-rju.y lhar rhm i( a oniru.rion hidi.8 og.ncy for rhc pqlormn.e orth. work lor which rhis Frmil n
<br />hsu.d (S(.:1097.Civ C ).
<br />Lcndcis AddEs:
<br />AIfI.ICAIfDECI.ABAIIIIN
<br />I ts$y ahlm undcr ,.nal'y of pcrjur, om of rhc follosins dcchra' bnr:
<br />Dcmliion P.mnlkb.no. Nolincllion Fcdcrol Rcslhlions (Tillc40, Pan6,
<br />_Rcqltrd klrq of NotilEabn
<br />I ccnily rhnr rhc lcdcrll Eguhr ion\ mErdins Nt $.\ rcm,vrl {r. nor lnplic$k ro r his lxrjsr
<br />-l
<br />ccniiyrhrr lhalc rcrdrhk pIl
<br />oktirxncc( xnd srrrr liwsrl irSr.
<br />ot$rc nrtrrioncd fopcn! tnr in\t^--r
<br />{rrn d strrcrhar rhc.b!c innnmdion i\.otrccr l3!retr
<br />$uildinr.o.srrucrion. dd hcrcbyruhorizc rcnR\cnrdirc\ orI
<br />coryly anh sllCilrlnd Counry
<br />h6 cnFnd Counryh lorc, u,i'n 'rrC-r -rV
<br />orrrt J Ot lUFur*rl lrtl.<,s
<br />t
<br />Underqround S-tt- t0 .)6,(11',') tibtut*'a.a
<br />Pole Bases l' ,.Ml
<br />Light Standards /7.\ l/-'-'
<br />Spas, Pool, Founlains v
<br />Signs (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Bondino / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Solfit Rouqh
<br />Ceilings (T-Bar Rough)
<br />Meter Release
<br />Rough
<br />FINAL l0-16 - lr k.ubal
<br />Notes, Remarks, Etc
<br />U-Jb F
<br />Site-Work
<br />Under Slab / Floor
<br />Service [t/]eter
<br />-0
<br />OIYNER BUILDER DEI,CARITION
<br />I hcrch, a{lirm lndcr li.ndh, .l Frjury lh0l I rm cx.npl itum Ihc Co ra.toF Liccns Liw for rh. rolhwinS rcasn (5...7011.5
<br />Busincs dnd Pi.lcsiotr Codc) Atry City or Counly whicn rcqutcs r pcm td co!{rud. ,hcr. imtovc. dcmlisn or quir an\
<br />slru.lurc. prd lo ns issuarcc- also rcqubes lhe q,pliclnr to, cuch pcrmir b fi|. a siencd idc'Enr $al hc or she n liccntd p!r{!d
<br />ro rh. piovisionr.frtr Conk,.xn\ Liccnscd tiw (Ch0plcr 9. clnnmcrcins lnh Sccltr 7{xx).r Divishn I ol rhc Busirrc$ lnd
<br />Pmlc$$ns Codc) or lhar hcorshc h cxctrrrr lhcrlrom lnd thc hssh lor rhc rlkelt .ftdt'r io. A., violilio.oaScclion 70ll5l,yany
<br />aurlicantloran€rmirsuhjelsrhc,ppli.,nrror.ivilt'cmhyornor roB rhan l'i!c hundrcd dollm (S5m).
<br />-1.
<br />&r o{ncr of rhc rorcny, an er.l!!iv.ly.onts.tiog wilh lic.nsd ontacrm lo consltrl lh. rorcl (Scc 7044. Busiftrs
<br />,nd Pot\sbn Codc: Thc Co.kr.tor's Liccnsc Law docs not opplylo !n Dsnc, otproFny who huilds ot imprcvcs lhcrcon.
<br />.nd who mnlrlcrs for such poj.rls sirh a Co Ecro(s) li.c.scd tu6u,nr !o dc C.ntElols Ltcnrc t s).
<br />Idcrcn undcrSRoon .B &PC fo,!hi\taon.
<br />WARNINCT lj{ilure ro scurc *orlc^ .onf.nnii{fi .orrtulc A unla\rlil. rtrd
<br />Appliconl or /\B.trl Si8nllum
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