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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BI]ILDER DELCARATION
<br />I hscby amirn und.r p.nalty oi pdju.y ll'd I dn d.np{ amn lh. (ontracloB License Lav lor lhc lollowins rwn (Ss?011.5
<br />Businss od Prol6sion Conc)r A,y Cily or County Nhich r.qrt6 a pdnh lo connruc1. alta. inprovc. d.folish or rtpat ey
<br />s ctR, r'or io irs i$udcc. also cqun6 rh. app|cer for such p€mi lo fit a sisncd sulond rhar hc or sh. k licm!.d i,GuMr
<br />lo rh. ,ovnio6 of tlE Conractofs Lic.n*d l,atr, {Chapid 9, Comnrcncins wilh Sation ?0i)0 of Division I oarh€ Busin* d
<br />Profcsio Cod.) or lh.l h. or !h. is .rmfl rnearom dd rh. ban tur th. all.gdi .xnFion Ant vioLlion oasation 701 L5 by an,
<br />apphcanlloraFmilsubjalsth..pplicanlloacivilpcnallyolnolnoElh fivc hundr.d dollm {6500).
<br />tA|Lrorraorrtpro6r',o.mrmplo)dsirhvr!6Erhrtrol.(orBnBri.n,$illdcrh.so*ddrl".endrbnor
<br />i.rodql or ofis.d tor elc (Sa.7044. BNins dd Profsions Codc l hc Contacroar l-icse Las do6 nor apply lo d o$n of
<br />thcpmpgly "no buil& or inFo!6 fi@n. atd *h. do6 so.h s!* hins.ll or hmlaor lhreu8h his or h6 oM employcB.
<br />ltovid.d rh,r snch imrmvdols re nol inl6'dcd or6.d for sL. lf. hosa6, lh€ hildins or inl,r!ffil is sB wnhin ooc )@
<br />dl conpLl'or lhc ()116 Buildc will hav€ thc bud6 of proving rhd h. or sh. dil d hild or imFDv. rh. Fopdy aor lh. po.p.* of
<br />-1.
<br />d oMd olrh. propdry. d .rlBivcly co racli.s wirh liccc.d coirados ro coislrucr $. projd lS<. 7044. B'triie
<br />and ftlfGir cod.: Tt. Conlr&lol s Lic.n. La$ d66 not apply lo e o*na of propdi, *ho builds or improv6 rhdmf,,af,d who conrEft hr rlch projers wirh. Contdclo(s) liccrEd pucu r tolhc Conlract6f3 Licce l,v)
<br />;: r,flff-'
<br />lt!!!.ll!!!!!
<br />I hrrbyrfln unJLrIsrlr!ol p.rjun onc oi 1)r lnllN\ in! rl{li,ar'ons
<br />-l
<br />hav€ and will ,n iitain a C6lificatc o I Co6dl to S€la-l6or. for Eorkdr conrpensrion, 6 pmvid.d lor by Sdion 1700 of th.
<br />Llbor Code. tor the FaomMc. of lhc mlt for whict the pmn 6 isu.d.
<br />_l h!r. aod vill nliorai. wortdr' conp.Gsrion iNurance. a r€quircd by S*r io6 l?00 oarh. ldor cod.. for rh. psaoflmc. oa
<br />rhe wor! lor which rht pdol !, isu.d My wl.ts coopcMrioi i6udc€ 6id d polk, nunbo a.:
<br />Policy Numba: E4n6l
<br />t'4 c€nii Ihal inlhcp.rfofl.anccoflhe work for$,hichlhis r1€flnit is issoed.l shall not cmployanyrEuon in any m nd
<br />e) ar b b.r.hc sulr.icrr r) rh. \.rl6j .oml'esrion larvs ol( !l'lirmia. rd asre rhar if I shotrld tKomc $hj.rr ro (hc
<br />$.1k.rs'.orpcBdnnln\tnJnsoiSnlion:r700of(hclahrrCodelslEll.ronhsirhconfllsirhtho$pi.vi\nJns
<br />WARNINCT Failure to su. *0116' coipo$dion cowr€ is unlrNiul, and shall subjd e onplorr !o nmin0l pdhie md
<br />.Nil lin.s up to on hu.dr.d rhoEsd doll6 ($100.000). in addnion ro rhc onrpcNtion. d.nag6 a provid.d lo. dr.
<br />Code, inl.r6t and anorncy s Wt.-,riii nif rr itrlrJn"riliiI
<br />lrlgrl,ltAJl)N
<br />I hdc6, amnn undd p..ahy oa pdju.y ftar I en licGdl undd lro\6ionorchaprd 9 (coiinM.in! $nh S.crion ?000) ofDirisio. ]
<br />of th. Rci.6s dd PofdioE Codc, dd my licosc is in full forcc od cA61
<br />coltrB.ucuolttllDllc Edc.y
<br />I htrby arrm undd p.noky oa p.rjory tfid th@ is r odtudion k din! .gd., for th. pafomnc. oflh. work ior $hich tht pann is
<br />issu.d (sft 1097. Ci!. C.)
<br />AITIJCAILDECI.AAdIIQtr
<br />I lEtby.mnn uidd p.salr, ol pdjury on. oa lh. aolloeinA dcltra' ioal
<br />Demolirion P6mic-Asb6t6 Norificar ion Fcdsal R.-lulolions (Tirl€ 40, Pan6)
<br />R.qui.d llnqolNorifr cdrion
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<br />c€nirythat lhcfederal!{ul.lio6 resddin8 st6ros roNv.l.re not opplicabl. to lhis pmj€cl
<br />lcdiayrh.r I havc rad lhi. applicario. dd $orc lhar rh.ahve iiiomario. ii coft.n I asrc ro conpl, $nh all Cilyand Counly
<br />ordin.ncB md srarc bq s eldidg ro buildi.g ,urhorte rcprsmrarirE oathis cnrod Coumr lo 0116 opon tlr
<br />aboc mcorion.d prop.ny ror
<br />ApDlictnl or ,\Aenl Sigmlurc:
<br />tLP€r'nitee nanre Iprinl):
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />llgfrt 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 />Bonding / Grounding / UFER to-y-i1 \ill"tc
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />R oof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rough
<br />Ceilings (T-Bar Rough),r<\
<br />Meter Release lo-1-,,7 17'20-11 lt-ttt*?€
<br />Rou gh Thla ir'D)
<br />Service Meter fr,j-IT
<br />7 -1629 \Notes, Remarks, Etc
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<br />FINAL
<br />Licdsc Clls
<br />-Li.dc
<br />Nu,trbd:
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<br />,.,"rtl,,lRrrt(l
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