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ELECTRICAL.INSPECTOR BECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcreby aanrm undcr pcnalry of Frjury rhd I am cxcmpr fmm rfie Conrrcror' I-iccns uw tbr rh. rollowinS rcM. (Sr.7oll.5
<br />Busincss und ft.rc*ion C.d.): Aoy Cily or conmy uhi.h Eirnnc\ d p.rnir io $nslrud. olrn. impmvc. dcnolish or E ar any
<br />(ruc'm. prtur ro irs icsurm., also Bquircs $c applice fo. such F.mit ro lih { si8ncd storcmnl lhal lE or shc is li€ensd pur${
<br />b rnc pmlisions ofrtE Conh(rofs Licen$d L!* (Cfiaprcr 9. Commrcin8 qirh Secrion 7m0 of Diliiion I of rh. Bulines Md
<br />Ptuacst,ns Codc) or thal h. or shc h cxcq,l rhcrclrom aid lhc bosh fu rhc ollcscd cicrprion Any viohri,n or S&rhn 70l l 5 brun!
<br />4rlicatrr ritr i t rdn subjturs rhc aprli.a.t ro a.ivil pcnanyotnor m.. rh3n fivc hundrcd dollis (S50o)
<br />l,.s owm, oirhe pmpcdy. or hr€mtloyB\ wirh {!gcs as rtet $h compenqrion. sill du tlr wurt dd rh. snrluc i\ mt
<br />in'cdcn or ofcrcd ror silc (SN 7044, Busimss sd Prolcsions Codc Tnc Conhclols Licc.sc t;'B docs Rr artly b rn ow#r o(
<br />rhc pmpcny *lk) hdilds or nnpn,B rhcrin, Md wh. dos su.h work hnnsclior hcscll.rthmugn hh o! hcr owncmplorccs.
<br />lrovidcd rhtr' such numrcmnll m mr inrertcd oro,lcrcd ftr sh.li howcvcr.lhc buiklin8 or impmvcDnl is sld wirhin "nc rcu
<br />ot coq,hrion, lh. Owmr Buits will haE th. bul(hn ol pmving lhnt hc or shc dil rer txih or irymvc rh. Irepcn, fo rh tqns ol
<br />l.r\rtrNrolrh.lmPcnv.rm.xchNirrlt..nrrJ.rtr,g$irhli.dn..,l.onnJ.nnt,co!'!rrrlr,,roitcrrscl.701J.llLAtr,r\,
<br />md Pn'fc$i, Cod. Thc cotrhcroa s Liccnsc tis docs .ot applt
<br />'o
<br />e owncr ol propcny who
<br />rfd *ho conrrncrs lor \u.h pn*cls wirhrC.dr!.r,nl\)liccnscd rursurtrr brh.O,
<br />b
<br />pg;LA8du0N
<br />I hcrcby af,nnlndcr Fnalryol!.iuryonc.trhc tollo,ins dcclullions:
<br />-l
<br />hnrr mtl qillnui rin. Ccn illc.t. of Consc loSclf-ln$rc Lr workc^' cotrDcnsarion. !\ pn,vidcd la.hySccrnnr.lT0Odtrhc
<br />L.'}Ir Codc. for rhc tcnorroh--c ufrhe *o* n, shi.h rhc pcnnir i\ ir\ucd
<br />I h,vcind wrll,hrnnrin workcr{.omp.nslrio ir\umm.. .s mquncd hy Sc.t ion ITOO oi rh! Llhor Codc, nx rhc Frli,nuncc .f
<br />lhc work r(r whih this !.rnrir is nsucd My{orkc('comn .sarion insur0tre caBicr .nd lolicy num$cr uc:
<br />Polic, N!nhd:JxpGs:
<br />l..nity rh, i. rhr p.rfoi,etuc.f rh. work for which rhis l,.nnir is issuod. I shrll.ol cmploy any I.rv,n in rny mrnncr
<br />g, slo hqlm subjsl lo thc workcrs co.pcn\lrion hwsolCalifofli!, lnd.srcc rhar irI .h.uld b..otu subjor to rh.
<br />*orksi compcnslion pnNisions of Sdioo 37U, of rhc Lstu CoJ.. I shrll. fonhwirh onlly wirh rhot Provisions..
<br />WARNIN(;] FIlurc kJ sum qorkcn' .omp.nsarion covcr,gc is uDhwhl. und shall
<br />:**tr,yu
<br />u{nd dollir\ (nlm.(]ll0). iI
<br />DIICIJMIIAN
<br />I hcEby alfinn uMcr pcnlllyolp.riury rhar I lnr [ccni{ undcr pmvisiotrolChaplcr 9 (comnEncirs
<br />ol rl[ Btrv cs d ltoL$i,nNCodc. n mv li.rn\c i\ i'r lull nmr x'll
<br />t" /71[{
<br />CAISIBUCIIQN.LENIINC.ACENCI
<br />I h€rby !flirn !ndc, Fnahy of perj!ry fi{ o.rc L\ , 6tr{M! ion lendin8 .8c*y ror lh. IErlormmc of lhc so* for wfiich lfiis !'cmit is
<br />issucd (Scc.1097, Cir. C.)
<br />APIIISANIDECIAf,AIIO!
<br />I hcaby llInn undcr ,'cnally ol,rrjur, onc of thc follou itrs d(la,ol ions
<br />Dcnrliiotr Pcrmit$Asbc(o\ Norificrlhn Fcdnal Rc8ulari.ns (Tnb 40, PadO
<br />Rcquircd btrn of Noliicaion
<br />lccnilithar rh. lcdcrrl rcgul0rions rcB0rdirg 0\hcsosrcnx'val c flor lmlicrhlclo rhn rojccl
<br />-l
<br />ccniiyth l h,vc rcad rhk ,pdicarion und st0rc rhal lhc
<br />ordirinccs rnd Sratc Lrws Elnrio8 ro build
<br />ftovc r.trrnni.d p()txdt lnr
<br />)drmply *irh allCiryond Counry
<br />::':i"r;/;r"-
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Lile Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipmenl
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Solfit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />Meter Release
<br />Rouoh
<br />Service It/eler \r
<br />FINAL l/1lL]lIq,t<+/91
<br />Notes, Remarks, Etc.
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