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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.OWNER BUILDEN DELCARATION
<br />I hcrcby afitn !nd$ ,cn0liy of pcrjury th,t I am .x.mfl rmm rhr C. lncroN Liccnsc Lf,r for rhc a.lhwing Eav,n (ftc 70:ll 5
<br />Brsincss md Pror.r\ion Codc): Any Cir, or C.uly whicn rquncs r E!.rit lo mnsEd. lllci im[ovc, dcmlish or Enot d.y
<br />struclurc. pritr lo ns nsuanc.. als rcquncsrhc n ,licdr tor suchp.mir b lilc, sigftd (dcmor rhai hcorsh. i! liccn$d prda.r
<br />ro rhc ,,ovi\ioni .l rlt Conrrn.ror's Li..nidd L!{ (Chlrrrcr 9. Comnrcncitrs $ith Secrion 7000 of Dilhion I of rhc B!{inc$ and '
<br />PBlc$ions Codc) or lhd lEor sh. ncrcmtr lhcrcltun dnd rhc l,!st forrhcalLBcd.rcfrfli.n Aryviolario.otS..ri'n70ll5byd.y
<br />lprlicrnr ior0 pcrmil subj.ck lhc rplicanr ro acirilpcnalryorror nrrcrh,n nv. hundrcddollas (5500).
<br />I. as owrcrorthc Frrny. or my cn{loyNs wirh ersc\ a\ rhcn s[ compcn\arn,n. will do rlr *ork nnd rhc stturm i\ hr
<br />inrctulcrl or olitEl lhr slc (5$.7044. Busjnes and Prclisio.s Codcr Thc Conta.rols Licc.sc ljq docs hor applyro an owmr ol
<br />rhc pmFdy wh. hxirds or ifrttrov.s rhkrn', dd sho docs such rad( hinNcllor hcrcliar rn,ou8h hn or h.r own cnDk,rc.\.
<br />lmvidcd rhal $ch improlc,mns N mt inrcndcd d otrcdd ror sslc ll ho{.!u. rhc boikti'rg or in{mv.nrnr i\ s,ki *irhin ,,nc Jrr
<br />ofcompldiotr. thc Osrcr Buildcr ai[ hrvc rtr hurdc. of r,ovin! rhd hc o! shc dil mr h{ild or iqmrt rhe porEl} ior rh. purlDs of
<br />-1.
<br />ns owncr ol rhc pn,lrny. 0m crclusiv.ly .onrrdins {irh liccn*d .onr'.lo^ ro conitud rrr ri,jecr (s.. 704.4, suqim$
<br />rnd t\.r*\iri Code:1he Conrocroas t,i.cnsc Lnw d€s no{.prly ro an owncr ol[opciiy who build(.r nnpmlcs rhcr.on.rnd who ontrds ior sxch pn'iels wirh r coda.ft,G) liccrscd pu^ldnr k, rh. Cunt!.ttr s Liccn{ t!*)
<br />-l
<br />amcxcmDr urdcr SEIion .A&PCturrht..dvr
<br />IYOBXE&::I:OMIEI{SAIION
<br />DLIIA.BAIIIIN
<br />I h.rciyalfirrundcr prnallyolpcrJuryoncoilft k lo* ! dcclrnriorsl
<br />-l
<br />hlvc oriwillm0intiinaccnific0'cofConscnr rosclr lnsurror wolids .ompcn$rion. ar fmvidcd lorbyserion l70oof'h.
<br />tibor Codc. for rhc pdfonmnc..r(h. *or* r.r *hich rne psmit t isslcd
<br />_lhole lnd willm0inrain w.rkcn compcnsation inru6nc., as cquiod by s(tion 1700 otlh. trhor C.dc.lor lhc pcrtbrmlmc of
<br />lhc wotk rn Bhich lhG pcrmil is issucn My workds co'nFnqrbn i.suranLr c.ricr fln poliy numbcr m:
<br />(s
<br />f3t..rJVJ c,or;+g*o \. (q
<br />I (nilirh r inrhc Frforir.rcofihc so lir whichrhi\ pcrtr,it is lsu..t.l shrllnol.mlk,trnyp.^otr inaiymanncr
<br />y,i\k)bc.onEsuhJcdrorhcworkcr'.onUcnsdiotrhss.fCalifdnr,rndJ!rccrhdiflshruldhc..nrsubjdrrorh.
<br />trork.^' .otrrfctrsllionpmvisioflsofScciidr l7ur.frh. Lrhri Codc.l \hill. {onhwirhcomtlt *irhrh& pmvisiotrs
<br />WARNINCT Failurc lo Burc rork 6 .onFns ion svcdg. h utrln*tur. ond sh,ll suhjcr ,n cnDlorr ro aiminal pcnanas ond
<br />civil nnes up lo onc hundrcd thousond dollirs (Slfi].fiD). ir sddirion lo rhc cost
<br />::::ifiulb:1q!:ffi1,
<br />DECI.ABAIION
<br />I h.rbyaftrm und.r Fnshyorpdijuryrhr I afr liccnEn undcr F,vnion ofChlprg 9 (!-ommncins *ili S(ri,n 70(x)) orDilisn,n:l
<br />of lhc Busimss lnd Pofc$ionr Codc. ud my licctrs is lull lorN Md cfiar
<br />Ioxqtrtv.
<br />u*".t[tl i$ !!Jl'-'-.* E f
<br />IONiIBIJCIIONII,IDTIC-&AENCI
<br />Ih.rctyrfllmu.dcrFrhyorDcrjuryrhdrh.r.isaLndsrtucrionlcndi',!rgc(,rorrhcFrromtucorrh.*orkarnwhi.hlirisp.rnrilis
<br />i$ucd lScr. -1097,Civ. C ).
<br />AIIUIANIJIECI,ASAIION
<br />I h.r.t y anm undcr Fnalty ol Frjury om of th. follo*ing dc.la,iionsl
<br />D.rrcfiion P.rnirsAsbcsros N6'ifi.lrion Fcdcdl Rqnl.rions (Tnb 44, P!n6)
<br />-Rcluircd
<br />t rl.r of Noin.diotr
<br />-l
<br />ccnify that lhc acdcrolrcSuklions re8lrdin8 lstrcslos rcDmvol*c trot.lrliablc to lhis pmrc{|.
<br />Lts-ri , r, , ** .",0 ,n* applicar ion o{l srare lhat thc otnvc inrolnEr rcn is corer. I aare ro omrly w h all ciry and counry
<br />oili'rtrtrrr\ J Srrrcl- *\ rthlingti hlildingc.nnrucrnn,. rxl h.rchy hori/c rc !lLhi\ Cirr uJ Counr! 'o
<br />cnt.r uFn IlI'Jt L ri6 2018rlxrc n'rDri,nrn F)ncny i,tr i',\nr.ri,r, f trrJx^.\
<br />Applirlrl or Alcnl SiAn.lum
<br />Pemile nome ( p.in0:Qot"L 0l
<br />Dolo
<br />Site-Work
<br />lJnderground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lite Safety /Low Voltage
<br />flre Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab i Floor
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />To rquerng
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Fa ctory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />Itlleter Release
<br />Rough ?zz.u.rts 5t 6t
<br />Service Meter /)
<br />FINAL 5/r7/x fl6b
<br />Notes, Remarks , Etc.
<br />COMMENTS
<br />1
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