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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Founlains
<br />Siqns (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<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 Rouoh
<br />Ceilings (T-Bar Rough)
<br />Rough
<br />Service lvleter
<br />FINAL Afl5t#iT/q//bt I )
<br />Notes, Remarks, Etc
<br />OWNER BUILDOT DELCAR-ATION
<br />I hcrcby trrrm undcr rnulry oa pcrjury lh0t I m cxcnpl lronr
<br />'hc
<br />Cbntmcbn Liccns L!* for thc folhwinE rcasn (SL!70:11.5
<br />Busincss md ftolcssioD Codc) Any City or Counly wni.h rcqurcs r pcnnil lo ('nslrucl- lltcr, improlc. &n,li\t or Ep,n 3iy
<br />(tucrurc. pritrto ils is\u0nc. lho requncsrte apllicanl lb, \uchpc.o,il ki filc r signc sarcmnr rhurh.rsh. il li.cnscd ttrsuanl
<br />ro lhc provnions.flh. Contrlcrors Licctrscd tiw (Chr,)lcr 9. Comnrcncin8 silh Seclion 7000 of Divnio,I of lh. Blsinc$ rnd
<br />Pofcsions Codc) or rhar he or \hc h crcmpr thcrcfrom Md rhc hash f.r rhc alk8.n dcmpri,r. Any viohrio. or sdhn 70.r 1 .5 by nny
<br />+pliclm forap@n rubjccrsrhc ipplica.t ro r.ivilpculryofno! nnc rhan 6vc hundrL{dolltr.(3500).
<br />-1,
<br />$ o*ncr ol lhc pmFny. or ny cn{loyes silh waScs rs thcn $lc mmpcnstn,n. sill do lhc wffk ud rhc {mrE h n
<br />i' utu[d or oaiercd lbr slc (56 ?O1.,1, Blsitus\ dd Prolcsbis Codc: l hc G,nrn.l( * t-iccne tf,w docs nor apply lo !n own.r oi
<br />rhc ampcny who hnlds or impmss th.mn. lrxl wl[ docs such slt himscll o. hcMll or lhmust hn or hcr o*. crphy..s.
<br />proridcd rhr ruch i.rImrtnk d mr i.rcndcd Dr oflcftd for eL ,l h.wcwi dr huildinA or iriptuvcm k $ld Bilhin onc rs
<br />ol con{,,crin tlE ONrcr BuiUs wil h!!e ltr bold.n of pFviry thlt lE or shc dil m! tirild or idrmt 0t poFny ror ttr puq-$ or
<br />-l-$owncrolth.F)pcny,onrcxclusivclr.onrrrcrinsRithliccnrdcontrlcrrsroq,nrrrucrilEpruJLrrlS..7044,Bu\iftrxd ft.tas\i.. Codc, 'f h. Coitr.ror'q l-i..nrc Law d.d\ nor rftly ro ,n own$ oftnrpcrry who builds or iDlrovcs thcrcon.
<br />and qho conlfrckforsucht,oicdswnh0A nn lkcnkd purunnr rorhcConrroctois Licensc lj*)
<br />-l
<br />amcrcmpr undcr Serion
<br />I hcrchy dl1nm utrrlcr r.nrltyol
<br />')cr]ury
<br />DIOAAAIION
<br />I hnvc anl w,ll nrNain , Ccd ilrcorc of CoflEnr r. sclf-lnsu( fn sor*6{ .onDcn\al ion. &! lrovidcd ior b, SNrio. l7u} oa rhc
<br />Utx* C{ic. for rhc pdfonMrc. ol rh. w.rk for which rhc ,)cmn is Nucd.
<br />-l
<br />hrrc ond sillmrintrir {orkcr' conrr.nsllion insurancc- 0r rcquircd by Sccrion 17fi}.r rh. bhot codc. ror rhc pdir'tumc ol
<br />lhe work rbr which rhis Fnnil is issc{ Mywor[cF compcnsotion i,NuruEccrri( r*lj-licynx'nhcr *c]
<br />I ccni,i thil nr lhc pcrtunnamc olrhc wo.k ior whl.h rhh Nrnrir is is$cd. I \h{ll nol cmploy any pcrson in rn} mnnn.r
<br />$ n\ ro h(<,m $$jccr torhcwork.rr onpcn\dion laws ol Colifonia. rnd emrhrr irI \buld hecon'c subj..r ro rh-
<br />wortcF' conpcn\ar ion pmvi\ions of Sc.rio! 17(x) of rhc l.!hrr C{nlc. I !tull h]nh*irh .onPl! wirh rho* ttuvhions
<br />IVARNIN(;] Fa,lurc ro {.trrc so*cis coNp.n$r rM shnll uhlcrr !n cn]nl.ycr ro sininrl Fnrhic\ Md
<br />rivil lircs up r) oic huidr.d rhon$ dolhn (..{ ol conDcnsrri.n- dJDEcs rs rrrovid.d nn rh.
<br />s..rnr l{)76 .fih. l rtrr ('dl. inr.r.d r
<br />I hcrcnyarfi irnundcr rniltyolFrjury I atn lienst undlr novision otChaprcr 9 (onftncins wnh s(rion 7000) ofDivistu.l
<br />or rltr Busnrss aftl P$lcsriorN Codc, ffrl my liccne i\ in full for$ and cflsl
<br />LicenscClass:-Li.c.r Nlnb.rl
<br />coNslltisuoll.ENrllclcrNiJ
<br />I hcrby 0firn und.r Fn,lry or p.rjury rhar lhcrc h a consdcrioh Icndi.g agcncy for thc I'c fomoncc oi rhc *ork fd shict rhh p.mi is
<br />hsucd lSc.. 3097.Cir. C.).
<br />d.PPIIIANI-DECIJAAI!]N
<br />I h.Eby dtim undc, r,coally oI pcrjury onc ot rh. fdlo*iis dc.lrrxr k,ns:
<br />Dcnx'lirion PcrmiG-Ashcnos NorificiIion Fcdcrll Resukrions lTirlc.l0- Id6)
<br />-Rcquncd
<br />kxcrof Nolificllion
<br />rnd Cohryro rnrcr rF,n rb.
<br />\Lm
<br />y,Id r'F rcdqrl,ocularrm rlr'lm8 st{{n< mmNLlJc n.r.rnLEtrhlc '. rhh nmFcr
<br />r \irygfir I r',," *.0 rr'n npllMriq'/ud {.rc rhirrhc atn( rnlomurion A concc! loaN rormnly
<br />d.MN\ll1d \Dh rr"\ Fh,,,c.fr,r't "l9f9,lqt",9,urhona mnlNtrhurcsar,hhc y
<br />Appllconl or Ase4nilsMltrF-L: D01.
<br />**n*.r1r,,, Looqt ;\6'\6-r-r
<br />btEtE
<br />COMMENTS
<br />Meter Release
<br />L€nd6'i Nrm:-
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