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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARAIION <br />I hcrchy rliirm utrds pctr.hy ol lcrjury that I u, cxcmpr lun lhc Conracror t-i.cns L,w for lh.lolloRing reasotr (Scc.70ll.5 <br />ansinc* {id Profcsio. Codc): Any Cny 6r Colnr, *hich reqlirc\ a Frnrir to conslrucl. allq. impmrc. dcmlth o cplt lny <br />srructuE.Irin b ns issumc. trh. nquinslhc amlic.nr lor ru.h p.rnil ro filc! si8rcd slllcm rhd,rcorih. i\ li...s.d Pu^urr <br />Io thc pbvhionr of rhc Conlrrrois Lic.ncd tjw (Chlrrer s. Conncftin8 wilh Scclhn 70oo of Divnion I of rh. Au\incs lni <br />ProrisstnsCodc)or'h!rtEdr.hchcxemtrrh.ratunundrhcbarnforrhcallce.dcrctrrrliotr.AnyliolationofSdbnT0-1l5bra., <br />oppli.r for 0 !.nrfi suhjNt lh. ,mli.an! lo a .ivil Fnalry of ndr mrc ihm fivc hundrcd dollffi {$500) <br />I. ar o*ncr ol rhe pmpcny- or my cnplort.s wirh sagcs $ rhct $L omp.n\alion, will & rt* wmk rnd th. srMtE h mr <br />inlcfticn or oilcr.d for sL (Se.7()44. Bunrcss rnd Pmfcrsions Cdlc: Th Co.rrrclols Liccnse Ll* dcs nor lprlyro i( owtur df <br />rhe pDpcrly rho huilds or i.umws rhcNr and who des such eofi himsclr or hcnclf o! rhmush hh or hc. o{n c'n loyccs. <br />provid.d rh r sx.h inJromnri e frn idtftkd d olTercd f(r sh Il h*cEr. rh. hoilllin8 or iqmEnEnt sH qirhi. orc }!E <br />.f6.plcrion, rhc O*ncr Buiud will hiw rtr t r&. olFoving rh.r h. or \h. dil mr hoiLt or ir96k rh.!)mFdy fo. fic luranc oa <br />-1. <br />asoqncrofthc Imncny. arcxclusivclyconk0crir8 Nirh liccnscd cotrrrrcror ro con(rucr rhc pm]ccr lS(. ?(x4. Br\incs <br />Md Pn,ftrsir Codc -l'hc Contacktr * Li.cnsc Uw do.r nor apply ro an own$ ot proFn, wh. bu ilds or imFtres rhcrcotr. <br />.nd *h' onrmds for such pmjccls wnh. ('omtrton, licc.serl pusuenr r{' thc Conrrucrois Licc"e l!*) <br />-l <br />rn cxcDnrutrdcr Sccl B &PC forrhisrmvnr.L/-/L L"-,;l ro (l <br />DIiCTASAIIQN <br />I h.rbyrlnrnundrr prMliyof )^-.Jury.ft.rrh. ioll.wirg dcclnrrrn \: <br />I hrv. dd $ill tuinrrin i C.diftlr. of Con\c t roSclrln\utufor sorkcn'.ompctrs nnr. !s povidcd lbr by Scctnn, -l7ll) ofuh. <br />Ljkr cl'dc. tor rh. rcrfomEc or rhc sork i(, which rhc Fnni is nrkd <br />I h vc ,nd eill mrinhin work.ra comrcnrd i(,6 insurnft.. r\ r.quircd by Sel nn 17fi, oi rlE tibor Lidc- fo, rhc Frtun&E-'c of <br />thc work lorwhichlhis pcrn is h$.d. My workcr' onlnctrsdion insu.incccffiis and policy numhcr oc: <br />-l.cniiylhorinlhcpcrfoirE..coflhcuorkr'orwhicnlhnp. <br />nir is Gsucd.I shall.or cnrrloylnrr.Fon in 'nyn'anMrw, * t, bcor subjecr ro rhc worlc^ conf.nrdn,n hss o,Csliromis. nnd aBftc rhd irI shorld bdom subj.cr ro th. <br />woft.6 coryrniarion t6vkio.s of Sdrion 3700 of rh. L2&y C-ulc, I shall. fonhwilh ompl, sirh tlns pmvisioos . <br />WARNINC: llilurc to surc srtc6 compcnsdion co\ensc is unla*ful. lnd .hall rubjlf,r an.mploru ro diminil lrMii.\ end <br />civil litrcs up ro orc hu lrcd thousnd dollln t$100.()00), in lddirhn ro rlr .osr oa.omp.nsario., drm8cs as prcvilcd for th. <br />.rlrr,olrl{ l.rhor (-lic. i' r'c( rnt nrtnN lt 4 L-t:(1".1u(f tolt( <br />^ <br />DEqJAA.IIII! <br />I lrcEhy amrm trndcr rnslly of Frjury lhal I 0m lie.snunder lmvision ofchrpls 9(commfting tirh Sftrbn 7000) olDirision l <br />of rhr BLsift$aid Ptrrlc$n,n.Cod., dnd mylicnse n in txllrdL! d.n..1. <br />CONSTRUCTI(TN LENDING GENCV <br />I hcrchy ufinm undcr I'cn ry of pcljury rhar rhcrc h a construcrion lcDdins ,setuy ftr rhc ruiroimftc or rh. *ork lor which l hh p.nnit h <br />hsucd (scc 3097.Civ. c ). <br />-/ro 14ffi, - ilil":i:'-Yt :t u lL t/- <br />p.m,,mnsm.,pr,n,,, A-' p rt c4 ao T4t 1<tetl <br />Underqround <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life SaIety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bonding / Groundinq / UFER <br />Transformers <br />Torqueino <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soflit Rouoh <br />Ceilings (T-Bar Rouqh) <br />ltleter Release <br />Rough srl t4 ll? -e") <br />Service ltrleler I <br />FINAL tolkltk Znrvg Ib7--' <br />Notes, Remarks, Etc r l--tr- <br />Site-Work <br />iA*-4.^l <br />AIIUCANIDEq.AAIIION <br />I hellry allim hdcr pcoalry of Frjury oN 6f rh. followins dsbrtrr ioor: <br />D.mlit ion Pcrmik- Astrslos Nolilicrl ion Fcdcnl ReBlld ions l l-illc tl4. Pan6) <br />-Rcquircd <br />Le(cr of Norificarion <br />-l <br />ccnilythat lhc icdcral rcsuhhns rcs&lins asbcsros rcrm\nlrrc nor,pplicabL r. rhh ln'lc{r <br />F <br />I