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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.OWNIiR EUILDER DDLCARATION
<br />I h.,cb, aafim undcr pcrolry of pcrjury lhal I m crctror 6om l,E Co racroN Lienr Lls fo. rh. Iollowing rcahn {Sec 70ll 5
<br />Busincss {xl Prof.rsn,n Codc) Any Cit, dr Counry shi.h rcqut s r Fmii b con{ .!, allci inpovc. d.mlhh or n'Nn y
<br />sldcrure. prior k, ils i*uarcc..lso rcquircs thcaprltant i(, suchFnnn to fiLo shned (a!€mnr lhal lf,orsh. is lic.nscd r!6ua!r
<br />lo thc pmisions of ih. Conra.l.rs Lic.nsdl Lrw (Chr/.r 9. C.mf.fting rirh S..rion 70(D of Divnion I of lh. Busincs md
<br />Pofe$bns Codc) or lhar lEor shc i crcnfl lhcrlrio 0nd th. b*is for rhc allc8cd crcmprion. AnyviolariooofSccliotr?0ll.5hyany
<br />lrplicanr fot a pcrmil sbj(lslhe aptlica ro ocivilFtr0hyoInol morclhan ftc hundrcd dollan ($500 ).
<br />I. N owkrofrhd ptup.ny.or ly.mpk,y.er wirh wr8e\ !s rhcir solccofrpco\rri.i. willdo rhcworked rhr dturm n nur
<br />i c.d&l or oliircd for slc ( Sc 704,1. Busincs Md Pmfcsrn)ns Cdc Th. C.M..t t Liccns. hw d.cs trol ryfly Io !n owncr (l
<br />rh.l,n|xny wtu hnild\ or nqmu rh.rdD. Lnd wk) dms su.h N* hi,n\cltor hcr*llor rhmulh his or hcr own.ntrh)rcs,
<br />providcd rhrr such iry)roEmnk uc nol inrcndLn.r.flaEn hra,lc.lt howcvcrrhc h,ildinAor irymwnr.r i srd wirhinonc )utr
<br />.l'conrpHbn- ltEowtrcr Duildcr will h!rc rhc hrdcn ol pmvhS rha' hc or shc dil tror build or inrr(nr IIE pmtsly for
<br />'hc
<br />puqne oi
<br />-!,
<br />aso*rcrol'rhc F.pcny- a'!cxclusivclyconl.eclir8 wilh li.cnscd.ontocktr\ lo conslru.l lhc ptr*cllscc. ?0,14. 8u\inc$
<br />Md Pnissbtr Cnl.r ThcCont.crofs Li..nsc t-aw do.s n.r rppltb ri.sn.rofflop.dywho huildsor im[orcs rhcron.
<br />lnd *ho snrncts lor such rmj.rts wirh a G,nrcdo(o ltcnsd nururd ro rhc Conrmcrols l,iccnsc liN).
<br />-l
<br />rrcrcmplutrdc. Sccrion-. B. & 1,.C. i.rl[is rcnsnr
<br />oai€ O*n€r
<br />]YOAtrE&):!AM[I,N!ArIA!
<br />IES.AXAIION
<br />I hcrchy arfirinundcr pcnally ol pcrjury olc ollhc li,lkrwirs d.clnratiotrs
<br />I htrvc ad {ill roinrdn a C.d i6.arc oi Conrnr ro Scll lnurc r'or woricF comr.n\a' ion- as provid.d t, hy s(r ion 1700 or rhe
<br />t{tx, Codc. tor lhc lerforrunce ofrhc *ork for which thc rEn,il h hsucd.
<br />I hrlr rid willdainrri'r *orkcrs comp.trlrri6n in\uramc- N rcquncd 6yScdn,n:lTmofrhc LrlntrCodc. f.r rh. FrfornDn.c of
<br />rhc sork Lrshi.h rhn l.rfrir ii tsudl Mtwork.^ on{f,n\Jri{in i'surmcc.dnin mdFlicy truithcr tucl
<br />Policy Nunberi-Erpid
<br />-lccnily
<br />lhr' in thc pcrr'oiimmc ollh. *ork lor shich rh,i lr.rnir n isrucd. I nrll nol.Ddoy rny pcron in any nunncr
<br />v' N k, htorr subjcc! io lhc workcs'.oorctrsolt,n l{ws olCaliforniu. and usN lMl ir I \holld h.cont srhJ..r ro rhj
<br />worl.r' d'nrpcnsllion polisio s of Smrnnr :l7ql of lhc Lltnr Codc. I \h:ll- tonhwirh co {,1, wirh I h.s ,mvhions .
<br />WARNINC: !.nilrc lo sccurc wortc( onEnsalion.ovcnSc is unh*ful. otrd sh.ll subFll an cnulole. lo sinrinal pcnalrics und
<br />civil fincs up to onc hund,cd rhouslnd dollaN (SIuJ,uD), m addition lo lhc co$ ofcompcnsalhn. daruEcs as pnvidcd lnr lhc
<br />sRri.,n.rn?6olr[cLatqandc.rnrcrc{!n<lanorrcy. lccs
<br />LIqENIEII;ANIaACIAA
<br />DESIAIIIIA!
<br />I hc,cbyllfirmutrdcr !.nohyofpc,jurylhar I!m liccnr]n undcr !rcrisi ol Chaptcr r) (Nmmmins *irh Sccr ion xDo) or oivntun l
<br />of thc ausiNssand Ptui.sionr Codc. atd mv li.cn* i\ infxllnJra inl cltcct
<br />CoNS TRtJ(:TI0N I FNI'IN(i A(;i:NCV
<br />I hcrchy lllinn u crrcnoliyofpc,jurylhal thcrc hacooshrctiotr lcndinsr8cncy forrheFraorroncc ofrhcwork rorshi.hrhi\ Fmir L\
<br />is{ucd rs&. l097.crv. c )
<br />A.PILICANLDICI.AAAII(IN
<br />I hcrchy JRim u ndd ,.nrxy .l pcrjury onc or rhc rolhrwing dltlfi ion\:
<br />Dcnrlirion PcnnnsArhsnN Norin.rrion Fcd.rdl Rcgrl,riotrs (liilc 41). Pnn6)
<br />-RequircJ
<br />l!(crof No llcati(,tr
<br />I ccnifyrtur rhc icdcnlrcguhii{,nsrcgarding r\tic{o\ rc'frnrlrrc n.rappli.nhk b rhi\ tn,Js:r
<br />l'rmilN nsnm I print,:
<br />Site-Work
<br />Unde rground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq i UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Condrtioners
<br />Roof Top Equipment
<br />Factor y Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilings (T-Bar RouOh)ilblrv /2,11 to/]? /a-
<br />l\4eter Belease
<br />Rough
<br />FINAL bl(1rt-6.Wm /62/
<br />Notes , Remarks, Etc
<br />COMMENTS
<br />Communications Cable
<br />Service [/eter
<br />tJndcar Addr.$
<br />-l
<br />ccnify lh lhrvcrc0dlhisapllic,liormdn.r.rhdrhcstsvcirroiin0rionis.om.t.I0grmrocondy*nha0CiryandColnly
<br />oftliMnca md Stdrc Lr*s Ebriog rd buildi.g .oosdcri6n. a.d hcrcb, aurhorn. rcFrenlariw3 of thk Ciry md CoDmy lo cnlcr upon llE
<br />ubovc mnrion n popcny for in spcct ion
<br />'rurDoss.
<br />Appli.ant or ABenl SiamluE: Delrl
<br />I
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