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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNIiR BUILDI]T DOLCAR-{TION
<br />I nc..by arm !bd6 p.n.lly oa pgjury rhar I a. cienfl &.m rhc ( ooraclo^' l-r.ns. t.s Ior fic followh8 re&n (Scc 701 I t
<br />Busin6s and Prcfsioa Codc): An, Cir! or Couni, which t.qu 6. rEm( ro coN,tua, rx(. impro\e. dtmoltsh or r.pat my
<br />srndure. p.ror ro ns isudcq abo requtB ih. applic.nl fo! such pq$il ro fi|. a s[n.d sl.lmdl lhal hc or si. is licdl€d, pusM
<br />ro rh.lmvisioB oa$. Co"ficroa! Li..ns.d LrN (Chal,td 9, Co,nomcirs *ith Sftlio. 7000 of Division 3 ol rh. BNina nd
<br />PoLssionsCode)orrhalhco,shei5crcnPrndctummd$cbsisforthcall.led.mprion.Anyviolalio.ofsdion701L5bvanv
<br />applicanrforapmirsubj-lslh.applicamto0civilpenahyolnolmorelhmiv.hunrbeddollrs($500)
<br />l. 6 orhs ollhc popdly. or m, dnployc wnh * as6 s ihci. Fl€ compeMtion. \ill do lhc \ork ad rhc ntudrc is ml
<br />i 6del or otTd.d aor ul. (Sa.7044, Busin6s dd ProlsioB Code: Th. Cod.ackv's l-ictuc tlw do6 nol aprly lo e o$td of
<br />rh.Fopdty wio hilds or itrrFov6 fi@( sd s ho d.6 such w* hirolf or h@df or ihmu8h his or hd o*n cnployG.
<br />PIovd.d rh.r su.h inptu!@dG ft nor inlsd€d or oiIq.d for el€. tf, h.$4s, dE hrilding or i,nplovdot is $ld snhin onc )@
<br />olcoDpl€lion, lh. Ovn6 Buildq will h.v. lh. b&l€n ofprovins itd h€ or shc did d hdd Dr impow fi€ ,topqly aor rh. FnFe of
<br />-l.
<br />so\hdolrhc tmpdy. tur.xclusi!.ly conl&clins {ilh lic@d @ntt.bu ro co6lrucl lhc projd (Sd 7Ol'1. R6mB
<br />md Prtrfeion Coder 1h. Conki.ba r t-i.d$ L6* do6 no! .pply b owns ofprop.nt *ho buil4s or inrpm!6lhdmn,
<br />6nd \yho.o Bds lor such projc.ts with a Co,traclo(r) li.o3.d puBumr ro lh.(onlracrort l-i.d. hs)
<br />I rn.\.m.t Lndd S(rio. .B & Pt Lrrhsrcsnn
<br />Drld: Orncr:
<br />lloa&8851(.q!ItENIALIAN
<br />PEqLABAIQ!
<br />I hd.by .firm und6 Foahy olpcjury onc oathc follo*i.g dddalioN:
<br />-l
<br />hav. @J will nrinlain a Cdlifical. of Coohr to S.lf-lG@ for Ertd, onrp.nsliol\ s Pmiid.d tur by S*tion 1700 of lh.
<br />Lahor Codc. ao lh. pqfomdc. o f lh. ro.t for $,ti.h lhc peon i! i$u.d.
<br />Zfit ma witl maurain wrl.n co6p.Bati@ iBumcq s '.qut d by sdion 37oo orlh. Llbor codc, ror rh. pdlomocc oi
<br />th. srt for which lhb Fmi G isqL My workdt anp.Ndiof, iBu.ecc .snn ari policy numbo e:
<br />1t/ < /;oa Wi ol<
<br />wc c a>z,b 2,1,> _6/-/q
<br />-l
<br />c€niry rhal ii thc pedornmc. ofth.work for {hich thB p6.nn is issNd. I shall nol dploy dy p6on in anv mdnf
<br />$ s ro b-om. s"bjer lo ih. wltqj cooFslio. laws oacalilomi& ed asrd lhal if I ststld bdorc subj.d lo rh.
<br />woir6'@mp.Mlionpevisio$oasclioh3?00ofrhcribot(L{etslull lonhwirt conply Pilh lhos DovisioB.
<br />\{ARNINC hilur€ lo suc \orkc comp.nsalion .orcEB. is unla*tu!. md shall subj$l a dplo,6 to €ininal pduXi6 d
<br />civil lin6 up ro o.. hundreil thorsd doll6 ($100.000). in addirio6 b rh. .or of comp.Nlion, d@a86 a providcd tor lh.
<br />Sslion 1016 ofthc Litor Codc, i.(dst md onorney s fc
<br />,',,,1-26'/b
<br />DECIaSAIIO!
<br />I hs€by ailm undd !6alr, ofFjxry lhal I m liftGcd undr FovBion oachapt6 I (con'n@ang wirh s.llion ?01)0) ol Divaion l
<br />oa lbc Busins sd Pnfeio6 Codc, Bi my licme is h full forc a.d.Osr
<br />D ?gbro
<br />t | -z'*'l 2
<br />(odila!,lcuorlElDllc-dcENcr
<br />I heeby altm undo paalryofpdjurylhal lhftis a cocro.lio.ladrs as cy to.lh. pdfolrMc. of lh. mri 6! wlnch rhis pnhn is
<br />issu.d (se. 1097. civ. c ).
<br />AIIIICANLDICIJ8AIIO!
<br />I hrdry,trnn unds poah y of pdjury onc of $c following dd ldaliofls:
<br />Ddolirion PmilgAsb6tos Nolificalion F.ddsl R.lulaliont(TIL 40, P5n6)
<br />-R.quired
<br />L.lr.r of Noliiic.lion
<br />-l
<br />.diry lh,l th. lcd@l tgulalioB teerding db6rot !dno\ al &c nol @plicabL lo rhis poj<1
<br />I cdify rhar I ha!. rmd this application ed surelhat rhc ahrrc i.iomation is coret. I alrc lo complyvilh allCiyand County
<br />ordinancd dd Srar. L5s rckrn8 ro blilding corohdioi. a.d h@by.ulhornc rcprcgrd GofthisCn,mdCounl,roms upon lh.
<br />lhr( mdr m.d prcpdt iur iNT(n
<br />Appllcrnlo. A*dl Sign.rurc '^,1!-_4:1.9
<br />Pcrmilee nanrc (prinl);A;cL""?l ztZztakpq e
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltage
<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 Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Rouqh
<br />Ceilinqs (T-Bar Rouqh)
<br />Meter Release
<br />Rough
<br />Service Meter
<br />FINAL \zlL/t'(hhqo fu:tt *r+>q,,l
<br />Notes, Remarks, Etc
<br />*"-"*,\ b----
<br />L.rdd'r Adlls
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<br />-------i--
<br />F
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