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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I n€r€by afinn uodr p.nally ol pdjury lhal I m cx€Dpl froD th. Contacrots' Lic.ns. Lsw ror lhc fdllo*in8 r.@n {Sd.70l Ls <br />Busin6s dd Prof*ion Co&): Any Ciry or Cou y whioh ,cqun6 a Frnt ro co.sltuct. drd. improE ddnolish or rcrEn oy <br />srtucru.. Fioi ro ils isumce, also r.quir6 th. applicer aor such pdnir to filc a s[n.d strtenor thar h€ or shc ie liccBcd p6uDr <br />lo rh. rrovisiod oflhe Conta.to.s Liensed lav (Chaud 9, Co'tunncing *ilh sdrion 70cio ol Dilision I oflhc Busincs d <br />ProfNions Cod.) or lh6l hc or shc is cr.mpl ihqefto,r ahd !h. basis for lhc .llcscd qoplion AnyriolalionofSc.lion 70.11.5 bydy <br />aptlica for a rsmn subjdc rhc applicor ro . civil pcnalty of nor dor.lhe fiw hun&.d dolld! l$50o) <br />I.6 ownd ofthe proFny. or my enlPlor€ wilh saB6 s lh.ir slc cor.p.nelion. Nill do thc wor& ad lh.eddw i! oot <br />intodrd or ollded lor sale (Sa.7044. Ausrns ed Pmfsio.s Codcr 'l h€ Conhrcrdf s l.iccNc lr\e do6 .ol applt io an own6 oa <br />rhe plrdy who builds or ibprcld thdotr di who &16 such \o* hnft.laor h*lf or <br />'hroush <br />his or h6 o\vn .mploy€6- <br />provided thal such inFowls e. d idod.{t or oIlrql lor elc.l[ hos6'6. ihc hildins or unPmvmr i, eld wirhin un. ]@ <br />ofcompl€tioE lh. Osn6 Builde sil n ve lh. hrda of F.ving lhat h€ or sh€ dil nol tlild or inrprov€ fi. fiopqq lor rh. pulbsc ol <br />-1. <br />6 oqq oalnc prop..ry, er.lusivcly conl,aclina wirh liceMd .onl'ac1oa ro .onlltulr rhe Fojd (sd 7044, BsD6 <br />and P,trftsin Cod. Th. Conlr.cro.s Lic.N ti* do6 nor aprlyto d ownd of lropdy-,-ho buildr or inprord rhd@n. <br />a.d who conrB€rs for such pIojds wnh a ContEcro(s) licdMd puB@l lo rhc conkiclurs Li.6. Lrw) <br />I m cxanpl Mderserion .D & P.C. torrfiis r6on <br />D.t. Of,n.r: <br />uaa$itsltlourElsArrQ!Dlodnalto! <br />I hereby amfln und{ penalty of psjury one of th€ tdloNiru drlarations: <br />_l halc a.d *,ill na'nuin a Cdincar. of Con$r lo S.lf lnsure aor workdl conD.nsalion,6 pmvid.d for by Sdio! t700otlhc <br />Labor Code lor lh. p{foIMc. of th€ wo* lor \ticn ltc pmnil is Gucd. <br />_l n!v. and u ill &.inlain worl€6' comFBaioo iGu,ance, 6 rcquircd by sdrion 1700 of rhc t bor Corlc. tor lhc pdfoddcc ot <br />fic eorlt for whi.h rhis pdftil is is.i My workdr onpolrion icuid. .did ed lolicy ,umb6 s€l <br />U \. r. r't <br />I cenii lhal in the pgformscc oflh€ wort lor which lhs p.mil is issu.d- I shallnol onploya.y pmn in.n, mmn6 <br />$ 6lo b.cohc subJ.cr ro rh. s 6'.onpctuarion la*s ofcalromid. dd igE thd ill shoold b..om. srbjrl tont <br />*0r(6 coipsMrion ptuviiiod of se.lion lT00 ol rh. l-ator Code l shrll. fodhwnh co lPly wirh lhos pmr isio6 <br />WARNINC: Failurc lo suc "0116 conpssalion covsasc is unlaqful. ed slau suhj(l d dphF to rnriMl poallis md <br />civil fins up lo on. hund.cd rhosd dou6 (t100.000). in addirion ro lhc con oa comp.Barion, drale@ a prcvid.d tor lhc <br />=: <br />Snrion 1076 olrlE LalFr <br />,,.,.1,t0v I 5 <br />Code inlssr datome)'s 16 <br />2018 <br />I hscby amm und6 p.nalty ol pqju.y $ar I u licosd und( p.ovision otchaprq 9 (conn n.inE *nh sdi.n ?000) ofDivision l <br />ol the Busi,N dd ProlsioN Code, and my licd€ is in tull lorc. md €OEl <br /><-3 \ 601 "l Poip \Oglqe. <br />coNiIalcuaNl.[NDIAcIG[dcI <br />I h6cby afiinn und6 pcnalty oa pojury rhd thac is a conntucdon Lndhg as6cy lor th. palomdc. ol rh. "ork aor rvhich lni! pdnil i, <br />bsued (Sa 309?. Civ. C.). <br />ATTIICANLDECIABAIIAT <br />I hftny arri undq penalty ol pdjory one oalhe lollowin8 d€cldatioN: <br />ocDolirion Pemirs Asbdos Norifi.arion F.ndd R.lularions (Tirl.40, Pd6) <br />Rdun d ldrdoaNdi6.aio. <br />I cdify rhat fi. fedsal BgulatioN Eaddin8 ehdros rdnoval a. 60r dpplic.blc to inis proj6t. <br />fi;liry rhar I have rcad rhs appl'carion ed srare rhar rh€ abovc inronnarion i! cotr(l I as6 ro coftply wnh dll ciry and counry <br />ordinancB md Stare ks ELrifls ro buildins consrruclion. md hreby authonzr r.pr6drariv6 ofthis Ciry od Counlyto mrd lpon th. <br />ah\€ mqnio.ed p.op€ny lor insp€clion purpos. <br />ApDlimntorAg.ntSignnlure <br />r2, "--l <br />,,,,"N0v I 5 20tg <br />Site-Work <br />Underground <br />Pole Bases <br />Light 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 />Bondin g/Grounding/UFER <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilinqs (Hard & Soffit Rouoh <br />Ceilings (T-Bar Rough) <br />Meter Release <br />Rough <br />Service Meter <br />FINAL tz/!0/:{a\><^/ <br />Notes, Remarks, Etc. <br />L.nder rAddrN:_ <br />----T--- <br />I <br />I