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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE IDiSIG.-couInaErurs OWNER BUILDI'R DELCARATION
<br />I hcrcby afltm undcr lcnilty ol pciu,y rh{ I an ci.mrr liom rhc ConriacroN Li.c.\c kw li h..followinr rc!$n (S.c l0l l .5
<br />B!\in.s urrl Profcssi.n Codc): Any Ciry or Counry which rcquins a Frmit lo con(rucl. allq. in,)lovc. dmhh or crah any
<br />Irucrurc. nrior ro ns hsurn.c. rl$ rcquncs ihc applic, for such pcrn h filc! siSmd starcrt rhal hcor sh. is liccn{d pususr
<br />ro lhc pmvtions olrhc Conrrlcru\ l-iccnscd Ltrw (ChlFrcr 9, c()onr..ing with sc.riotr 70oo of Dilkion 3 oflhc Blrinc$ and
<br />Prcr.\rio.r Cod.) o. rhir h.orsh. ncxcnrpr rhcrufrom,nd rhc b.sis for rhcaltscdcxcmprion Anyviolrrionors.crirnr0ll.5l,yany
<br />aprlicanr ro pc,nrir rbjEls rhc lrplicanr ro a civil !.aalry ol not mE rhln livc hundrcd dolle. (s5m).
<br />L * dwn$olrhc tbJrny..r mycnrloFrs pnh wrgcs as lhcn sE comncnsoti.n. willdo rtE $o& dnd lh. {EtuE is ml
<br />i cndcd or on'crcd for slc (Sa.7(44. Busi.c$.nd P,{,lc$io.s Codq Thc C.nta.rors Lic.ns Law drcs nol applt ro 3n owtur.r
<br />rhc pDFny sho hildi or ir{mws thmn. *d who d(B s-h *ork iirn{ll or hcr*lf or rhou8h hs or hn oNn c.rpLyces-
<br />pNlided lhat such intrcwnh e nn inrcnded o, otlbL{ f{, {k. lt towcv.i Ih. buildins or in{revcnEnr h sUsirhino* iu
<br />ol @trll,k n,n. lh. Owndr suildo will h,vc rhc bordcn ol Eoving th,l h. or shc did nol itrild or imptr)E rhc poltny tu rh. purPs ol
<br />-l.
<br />rr.si.rorrhclrfirp.ny., lcxclusivcly.ontu hns sirh li.cnscdconrr0closloonntucrrhc pmFd (s.. 7044.8usms
<br />ar.t ftotrxsion Codc Tnc Conl mdoi s l-iccnsc Law does mr lmly r. u owEr ol prol).ny aho bu ilds or inrprovc\ rhcrmn.
<br />ud wbo conrsck ror su.h tloi*k *irh a Coma.k'(9 lkcnscd t,unu'nr k, rnc Conrrerois Lntn$ Irw)
<br />lrnr.\.D,i nftl.r S{rnf, .lJ & I)C nn rh. '.i$ r
<br />lrrlr ()snrr
<br />}U8trDII5.:C!}MENSAIION
<br />DICI.AB^IIQN
<br />I hcrchy al'l tnr un,lcr rcnah!oIF-rj!ryodc.frhc tulk,win8 dc.l&riionl
<br />Ihrv.tunwill,MinllinaCcnific.tcoIConscnrloSclflnsurea.rsorkc^ codFjnqrhn. !s providcd forhySccrionl7L{)otrhe
<br />libor Co.lc. ror rhc pdrormmc olrhc mlk ror whi(h thc pcrmil is issued
<br />lhrvc.ndqillmri.lalnworkcrscompcnslrioninsurancc.!\rcqlircdhyScdionlT0Ooillf,l-lborQc-nrlh.Frfonnn.dor
<br />rhc *ork aor whi.h rhis p.nnir y porlcr' coflrprnslrion io\xrs'r.. .adicr a poli.y numbcr uc
<br />\
<br />C 4t(rb
<br />Ic.nilyrhrrirlhcli.rlornEn..olrhc*orklorshichrhisncnn i\i\{td.Ishlltrotcmnloynny|tr{rinrny.r.'
<br />{' rsr,r hccoN sh]cd ro rhc workc( compcn\dn,n hw\ orcrlii,nir. kirtrccrhalifl\houl,ltto,csthJtdbrtE
<br />*qkcr'conrr.nsdionprovi\n,nsofSccri(,nlTmorrhcl;'tirGntc.lshnll.l'onh*ilhconrly*irhrh,rn(r^iois
<br />WARNINC Failuic ro h..urc workcr( conpcneti.n corcraSc h unlawtuL and \hall {brc.t !n cnrtloycr to riminal If,nrhi3 and
<br />.iril lind ut ro oft hutrdrcd Ihouslnd dollos (310o.(DO). in oddirnrn n, rh. c.i ormnpcnsrriotr. darMscs !s providd lnr rhc
<br />SNtion 3076 of $. htrr Codc, i.tcrcsl otrd altofty\ fecs.;";j.&$ ;;:;x xlnGr.\
<br />LICENSED CONTRACTON
<br />DECIJAAIION
<br />I hcrchy affim !.der pctulry.fp.rjury th{ I ar liensd uodn pruvtion olChaprcr9 (oitumi.8 eirh scclhn 7OD) ofDiltion 3
<br />ol lh. Busincs ond Profcssioos Codc, un my lic.ne n io flll r$e nnd .fiei.
<br />t-W cbffi4r7
<br />,",", .\rli\t ".,,*..x-EF4? ATYLE-I s-'I<11
<br />IaISIBIJCITSNIENDIICAOEICI
<br />I hcEby trlfirnund.r F!0hyolp.rjury rhll lhcrc is a onslrudhn kndins,8ctr,16r thc p..foirMrcc oathc *o for shichrhG Fmil is
<br />hsu.n (Scc. 3097- Civ. C.).
<br />,IIIII(ANLI)ICLAIAIIo!
<br />I rBr{ry.ltirr uMcr |xnally ol'p.!jur, onc oarhc i{nh,ins dcclarrrn,n\:
<br />Dcn,lirion Pcrmit A\b((.s NorillcrlFn rrdcrnl RcEuhrion\ ( lirlc40. Pld6l
<br />Rcquncd krrd olNolilicdhn
<br />4rffiffiffiffiil;##ffid;,-,,il::-::ffi::rv'wvak L'...
<br />P.mi,cn.m,p.in,): x /}ubtltrfl\k$
<br />d Colnrr ro enrc. up.n t
<br />bbrg
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq i UFER 9lt{B L{a4Ca)
<br />Translormers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soffit Bouqh
<br />Ceilings (T-Bar Rouqh)
<br />Meter Release ultn)
<br />Rough
<br />Service Meter 9lr(t /4ArD,
<br />FINAL I lutrt.)
<br />Noles, Remarks, Etc.
<br />Communications Cable
<br />9lrdts
<br />WXW
<br />tJnd.ar Narm:
<br />-
<br />trndrr s Adrlrc$:
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<br />I
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