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ELECTRICAL.INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundino / UFER
<br />Translormers
<br />Torqueing
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rouqh)
<br />Rough
<br />Service lvleter i
<br />FINAL trlZftl\t
<br />Remarks, Etc.I'r I
<br />l_r9 - xl.a,-f Rzltl
<br />t-v'v \.-:-=-
<br />OWNER BUILDER DELCAXATION
<br />I hcrchy rnrm utrdcr,'cnall, ol tcrjury lhot I m.rcmfl rmm rht Cbnracro6 Lk.ne liw f6r thc lbllosins reasfl (Scc7031.5
<br />Busincs and Pmfcsion Codc) Any City or County shich r.quircs d rqnil ro conslruct. alr.i nntn,vc. d.mlhh or Enqt any
<br />{fl.ruc. rh!ro ih nsuancc. als.cquircs thcap0licotrl tbr su.h pc.mi b filcr iiencd s,loftnt rhai tror shc is lic.n\cd px6uanr
<br />ro lhc povnions or E Conra.rols Licens{ hw (Chafl 9. Connc"cins sirh sccriun ?00o ot Division I ot r,rc Ausinc$ and
<br />IltrcssionrCdc)orrhlrh€orshchcr€m,,tlheiefronrMdlhcbasirrorrh.aucecd.xcmrrion.AnyviolarionorserirnT0ll5bruy
<br />nmlicrnr ror a p.nnn ruhjftrsrhc snplicanrro acivilo.tralrrotnor fttrcrhan 6rc hu.drcd dolltrs(!s00).
<br />I.r\o$ncrolrhclml,cny.ormrcnrllo)ccsvirhw.Scsrslhcirsrc.{nDctrldi.n.silld.rhcwolklndrh.sldtl{cnEn
<br />i cnd.{ d.lTrdl for eh ISN ?01.1. Eusi.c$ lnd ltoltsions Codc:1hc Conrlctor's l-iccnr L1e do.\ mr altly ro ar osn.r.f
<br />rh.F)Fny whl hrilds or inlmv.s rhcNn.ort rl..)d(Es$chs.* hinN.lrorhrisclrorrhft,u8hhisorhso*ncfrplorer.
<br />Frrilcdrhlr su.h impnrrcnrmm mr inrMddl oroflafrl aff elc li tx,scrr. ric hoiHitrS or inDmrcmnr is v,ld wirhin onc re
<br />orNnl,kii,n, lhc O,ncr Buiklcr qi]lhlw rhc budcn oflmvin8 lhd lI or \h. did mr buikt or irrpr.v. tu ln,Fny fitr $c PlrF,sol
<br />l. ns owtur ofrhc pmpcny. !mcx.lusivcly.onlndirr8 sih licctrscd cotrtrcusro con\rucr
<br />lrrl lrotssionCodc: Thc Conh.rofr Liccnr. Lr* drxs nor applt h !nosncr oi
<br />dd who cotrr.dch ttr slch polc.ls sirh a Contrucio(, Iiccned ,trnuinr ro rhc
<br />DISLAS{IIIIN
<br />I hurchy,fiflnxnd.r l.nalrrorFrjrryonc oirhe toll.wins dcclnrations:
<br />I hrk {rl wiu auinrain r C-cnifrltc olconscnl h Sclfinsur. f(r *ork N comp. slion. $ [ovidcd for by Ssrb. 3700 ol rh.
<br />lihr Codc,lor th. psloi,umc ofthc work lo, which rh. pcrmn G issucd.
<br />I hav.ihd willmlinirir wo crr .onlJjcnsation insumNc. ar rcquiRrl by Sariotr 3 7(tr.f rhc hbrr Crrlc, for lh. Fformncc of
<br />rhl worr ror which rhn ri..mil is i\su.n. My*orkc$ com!.ns.liotr insurtr.ceca cr art noli.y trumhcr ml
<br />-l
<br />ccdiiyrhd inrlE pcrlonEmc of rhc work forwh(h rhr
<br />'l.rmn
<br />i\ i{lu.d.l slrllnor rtrlployrny l).i$n inrdrntMnd
<br />*r r\ ro h.o f, sDhjoi n, rhc {orkcr compcn$rion h*s or Calilorni!. rnd i3B rhar ill {.o!U hc.o E subFcr ro rhc
<br />workda .on!F \rrrn lovi\ion\ of Scdi{x -r7ulollnc lnhn Cqlc- I $rll. hnh*irh.ourt *ilh I
<br />$AllNlNG: f1nhtrc k) $ctrrc $ork.r\ coflf.n\]ii(nr ..r.tu9. n
<br />ciril ,incs up h o c hutrdrcd rhor\rnd dollr! lSllX).lXX)), in;:,jJilir'"
<br />DECI.AIA]JON
<br />I h.rb, ofatrnr undcr F.nohy ol pcrjury th.l , m liLlnei und.r pmaliiod ol ch{prd 9 {.shrEming {nh sccrion ?00o) or oivisnrn 3
<br />ol rhc Bu\irr\s,trd PrnasnrlrCodc. {id 'nr licrf\r i\ in lullf(n.c Nkl.,fc.r
<br />COISIBIJCIIONIII DI!C.{GIiNCI
<br />l lrcNby rr6.in und.r ttn yorp.rjoiyrh.rrhdtilrcotrj Lri,ilcndiiErscicyrorrhclcrrortunccoirhc*orkrrruhi.hrhi\trr.riri\
<br />is\ucd (Scc.1097. Civ C )
<br />AfIIIIANI.DES.AAAIPN
<br />I H,y afiim undcr Fnally of p.rjury oft oi lhc roll,wine d*laririonrl
<br />Dcmlirkin Pclmir ArbcsrosNori,icari.n Federal Rcslldions (Tnls (). Pon6)
<br />Rcqxncd Lencr of Norificarion
<br />l.cniry rhd rhc Ldcrdlhauhrn)n\ rgudin8 r\h(io\rrnn,vrl rfrlicJhL k' rhi\ J,(IL!
<br />-l
<br />ccnifyrhal I havc rcrd rhhumlicrlion icorNl. I rlre !o comrly *,lh rllCityand Counly
<br />ordin nccsind Slalc Lrss Elaliun,fr.\cdrrlivc\ ol rhi{ Ciry md
<br />rh)vc nrnlioncd p('Itny lar in
<br />\pt,li( l or,\xrtrr Si!tr ru.t b
<br />APPROVALS
<br />Sub-Panels
<br />Ivleter Release
<br />AA}Lq
<br />Notes,
<br />'?tr{*7
<br />ll
<br />knd.ls Addre$: _
<br />e-
<br />F
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