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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE tD/stG.COMMENTS OWNER BUILDEN DEL(ARATION
<br />I hcrcby artrm uodn !.n!lty or pcrjury lhlr I m cicmpl lmm rhc C.nrt.bn Ltcnsc tj* for rhc follo$in8 fa$. (s.c 70.11 5
<br />Business arn Prolc\si{,n Gne) Ant Ciry or Counry *hih 6quircs tr Frmit lo connrucl rlls. nryrolc. &mli\h or EFn nny
<br />rmdh. prior ro ns niuan.c, .t$ rcquircs thc !pdic0,t for such pclm ro nk r sised rlnrcftnr rhtr rE or shc h licctr$d plnulnr
<br />ro lhc Fovkions ofrtr Contracrols l-icensd ti, (Chaprcr s, Coon n.in8 with Scclion ?000 ol Dilision:l of rhc Bnsincs itrd
<br />Pnfc$ions Co.lc) or thor hco! shc hexcmpr rhc..lo,n{nd rhc bnsh for rhc 0l1c8cd cxcmplion. Anyviol0tionolscdion?0ll.5hyany
<br />ntplic,nr ror n p.mn subjeIs rnc appliclnr ro acivilpemhyofnot morcrhdi lv. hundrcddollrs($500).
<br />-1.
<br />ss ostur .l rhd lr.Fdr, or my cnplolcs wilh r08cs as thct slc comp€ncarion. sill dD tlE edk atrl lhc ntrtw is ml
<br />inkftr.d or oficrcd lor $L (S( 7014. Busimss lnd Pr.fcsions Code Th. C.nta.ror's Li.cnsc tjw rkrcs mr ryIlyt,,nowmi or
<br />rh. pFFny sh. hoilds or nr{mhs rh.m( lrl wtb dB skh mlk himsclfor turclf or rholgh hii or h.r.*n .nl,lo}tcs-
<br />piovidcdrhat such numwmnr\ @ mr hrcndcil oroficGlfttr sk Il lbecrd. rh. ttrildina ot inrmEmnr is rld sirhino* )td
<br />ofdrllLikn rtr ownd Build.r qill h.vc l,E hurd.fl of pmvins lhal lrc or shc dil nor hxild or impoE dc lmFny lh, rlE puqn{ or
<br />I. Lsuwrerorrhc ptuIcny. amcxclusivcly conracrins wnh li.enscd conrract,s r...n{ru.r (h. pmlccr {scc.7Ol,4, Bu\inc\\
<br />od eoission Code: thc Conrreioa r Liccn\c L,w do.\ nnr amlt tt a6 ownct of |trol'.ny qho bu ilds o, inrpn,vcs rhcrcon.
<br />0nd *h. o Ecr\ rti su.h pmj.cB wilh a Conido(s) liccnscd punulnr lo lhc Cont&ror's Liccn* trw)
<br />I n.rcn,lrrunLl.rS..ii,n, lJ {PC l(! llri\ i,'a\r,
<br />I){r. ()$der
<br />w()RKFRS', C()lUPl]NSl{l t0N
<br />I2ECLI.BAIION
<br />I hcrcty aflnmldcr pctrrliy urpcrluryotrc ollhc rblbqirS dcclar0rion\:
<br />-l
<br />havc a will moiorain ! Ccnific*e ofcooscnr ro Sclalos!rc ror sorksl compcnsation. as pmvidcd fu ily sNrion 3?00 of rhc
<br />uh)r Codc, for rhc p.rrormrcc of I h€ wort for $hkh l,rc psnir i\ i\rx.d.
<br />-l
<br />trk a.d *ill tuinrain wo.kc.f comp.nsnlion innrorcc. !s rcqutcd by Sccr iir :1700 ol rh. bnor Codc. hr lie pcttortuncc of
<br />rhc*'k,orsh'chrh^Frnnri.FqnlVyAmlolm'nncn{r'on,n.u,rn.rtmc'JklFl'.ynu
<br />,,",,., flt,zer! ltzl#
<br />-"^*,,60co/ 5e1/6 o
<br />lcnify rhrr i. rhc pcrroirruEe ('llfic work lor *nth lhis rErmir is 1\$.d. I drll trol cryloy lny pcrsn in dy nrnEr
<br />w .\ ro h+om cul,jd lo lhe so cs..mFn\rrion lnssorc,lirornia. tndlsEriar iflsholld trtotu hi.rrorhc
<br />sorrLrs co,npctrsli,,n pnvtions ofS(rion:17{nofrhc l-rh, qrdc,I shrll. r'onh} ilh c.nDl, sirh rlbY !tuYision\
<br />WARNIN(;] Frilxr. r) scurc qorkcr ohpcnslrnrn cotrl3e i\ unlawful. ,trd \hall subjNt alr cnrpli,yc, k, dimiml lEmlric( trnd
<br />.ivil fircs up ro onc hunircd lhouqnd dolhN ($l(r)-(xD). in lddnion b rh..osl ofconpcnsrrion. d!tuCc s pravidcd for rhc
<br />s.cr'oi rrr76.f rhq,lihr fo,t. inrcre{ rnll0norruy \ r.c..;,;,"6J;/)4" ;;l;E-
<br />UCENTED-(!)NI8AINIB
<br />DECIJNAIIAN
<br />I hcrcby oftnn undcr p.nalry nf llcrrlry rhar I e lie.s.n und* p.virionofCtotl.r 9 (odmming wirh se'ion ?uro) ofDilnbn:l
<br />ot rhc ausi,rc$ nd Pmfcssions Cod€. ad ny li.cns ir in anll aord tnd .fter
<br />CZd o C3 DZ 6
<br />o"., ' 4 L.,*,*,
<br />lollirall]IloNrlN[Iacl(iEllr
<br />I hcEby afirm undcr I)cuhy ol Detjury rhat rhm is a conslNcra,. lcdins asency fo. rlt !.rronmnc. of rh. wor* for *hi.h rhi\ Frmn k
<br />isu.d (Scc 3097. Crv C.).
<br />AIILICANIDECIdAAIO!
<br />I h.rt, altim uds I]...lt, of p.rjury oR of dc followin8 d(hral io.s
<br />O.nFlilion Pcnnik.Asbcstos Nolifio'i.n Fcd.rd R.eul,rions (Tnb 40. PIn6)
<br />-Requircd
<br />Lcrrcrof fiorifEdir.
<br />l.crrifyrhar thc lt&r0l rc8ulo I ion\ rc8uling !sb.io\ rNnn)vrldc nurllltlic0ht nr lhis pnI..r
<br />-lccniiyrharlhivcrcudrhissmli.arionardndrcrhdlhcaholcinlormarnnncor.cr.li81ero.onl['lordinarccs and Srare li*s el,iing b bnildinB .onsrfl.ti.n. dt hcrcby aullnri.. rcF.\ddurivcs ofrhn Cil
<br />y wirh {llCiryund Coutrr,
<br />itx,vd nM(ioncd !tup-ny lo irrpcclion
<br />At,pli.nnt trr AE.nl Si[nnlu
<br />Pcmi(@mmer,rrnr: Y- f2rn-f
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Lighl Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondino / Groundinq / UFEB
<br />Translormers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilinqs (T-Bar Rouoh)
<br />Meter Release
<br />Rough
<br />/A
<br />FINAL l-29-11 YN{.10
<br />Notes, Remarks, Etc
<br />--+
<br />Service Meter ft..:--_
<br />l.n,lcr\ \Jnr. _
<br />lrFdu''" Adi!.$
<br />-
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