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APPROVALS DATE ID/SIG.OWNER BUILDER DEI,CARATIoN
<br />I hcrehy rfirm lndcr penllty ol F.jury rh l rm cxcmfl fotrr rh. Co.tra.ros Ltcn$ LaB lor
<br />'h.
<br />forloring rctr$n lscc.70rl5
<br />srsincs rnd P.olt$ion C r) Any Ciry or Coutrly trhich rcAntcs a rrmil rn .on(rud. alrc!. imnlovc. dcnmtish or rcnot .li
<br />qflcruru, rnnb irs isurn.e. rho rcqut s rhc rpplicrnr f{tr such pcnnir i{, filc! \igncd dlremnr rhlr hcor shc i\ liccnscd pursuir
<br />ro rh. thlj\n,ns oi rhc C.nrracttr s l-iccnkd bn (Chsplcr 9. co'nnrcncior wilh Scclion Toq) o, Division 3 otrhc BusnEss an.l
<br />Pnlcssiotrs Codc ) or rld h. or sh. h .xc rtrr rhcdfto end rhcbo\i\ fir rhcrllcgcd drcnprnrn Any vn'hrn,nofsdrionT0.ll5 ht riy
<br />amliunrlnraFrmilsubjclsrhc.pplicanrroocivilricn.lryornornbsth0nfivchundrcddoll.rs($500)
<br />-1,rsowncrolrh.pmp.rly,rtrmycmployccswirhwases6rhctsolccotupcnsdt,n.willdorhcsdkundrlr
<br />fl.imiqn.r
<br />inrcndcd or ofiircd ior $lc (SN 7014. Busircsr and Pmfc$i.ns codc: Th. Cont,.ttr\ Lkcns tjw d.cs iol rp/y lo orowncr af
<br />rhc J,mFny qh() hoildr.i i'hrr.$ rh€d.. u'd wh) dms s-h wort himsclfor hc6.lfo. rhmugh hi\ or h.r own c'nnk,tccs,
<br />providcd rhar \uch inpmunEnG @ ml inr..icd or oflar.d for slc. lt hoNcts. rtE trildin8 or inlmEnEnr is sld wirhin om }!s
<br />otcomDLri'n. rtE O*ncr Buillcr u ill hate rnc &nlcn or pmrin8 rhd lt or \hr dld fr, build or nnpruvc rhc p$trny for 6c ,'u!x'e oi
<br />-1.
<br />0r owrcr or thc rorcny. dnr cx.lusircly c.ftr.rin! wilh li(n\.d .onra.bs ti ..niru.r rh p$r.d {Sc.. 7044. Burinc\\
<br />ndl Pn,li\si Codc lhcc{,orrnclor's Liccnsc Lawdoes nor 0pnlyro 0nowncrolprotcnyeho buildsor inrprovcs rhcrcon.rnd uho onrmds ror sn.h t'tu,c.G Rilh a C.nrhcb(n liccn\cd pr\ua b rh. Contdor'1 LiLr.sc trw)
<br />-l
<br />amcr.mo undcr Slclion
<br />]rottrEBs:']goNfENtA.IloN
<br />OECLASAI]IIT
<br />I hcrcb, afln undd r.nrhyof,.rjuryonc orrh.lnlb*ing dmhnri0ns
<br />-l
<br />holc ond willnDimlin, Crc.rifialc ol Con*nr u S.lfln\wc fq workc( c..rr.nririon. $ Fovidcd for bySr.rionlT(xlofrhc
<br />tibor O,tc. aq rhc pcrfonBn c dfrhc work [d which rhc Fn,ir is issucn
<br />I hivc rtrd trlllnr.iNdir torkcrf .onrn(t!rri( i'Iurrncc. r\ rrquncd hySc.ri,nr lTlX)ol rhc I]lrtC.dr. forrhcl[rror ht...f
<br />i( trr nh rh^rrrnnr r rqGl Myu,trkrh
<br />,q ,' a(U- A t-
<br />'clmp.i\rrion in\uran( caricr drlF,li.y unbcr rc:
<br />/ <".r 4 _Z-.t .
<br />/. /. t"
<br />l.cn'li rhrr inrhcp.rr(r u,f,c ofrhc $ork f{n *hich rhis p.nnir n n!ucd.I shrllnor cmployanyp.(on innny nr ncr
<br />e arlo lr.otrr \ub.i..r ro rh. sorrn\ onpctr\r.oi h*\ otCalif,nnia. Md rErcr rhd ifl \lx,uld h.com \ubjr.r ki rlr
<br />wo*crJ .onr!.n\nrnnr F,visi(,ns of Sd.rn$ lTrD of rhc Lhtr C.xlc. I shall. fonhwirh comrly $ irh rli,{ povi\nnr
<br />WARNIN(;: Failurc lo s.urc *orkcr' onpcnslrion covcnsc i! utrhviul. in.l shall sutccl in cmtlqlr h simnul Ilcntrhi$ and
<br />.ivil lincs up kr one hundrcd lhouqnd dollar l$l(N).000), in rddirion lo rhc cosl ol com!.nsatnrn. duu3cs !s nn* cd tor rhe
<br />sr..r' rf r, irr5. I Jhe' ci\t.. I h...r JnJ rh1a.)'. r. -4L4 Appllert:
<br />I hcrcbyalfi undu pcnlhy.lrrjury thd I am licutrEl nndc, pmvasion orch+tr 9l.onmn.ing wnh sc.rion?00o) olDivision l
<br />of rhc ausin.* Md Pmfe$t,.r Cod., aJd ny liccnr is ir lull ntrce ond crtcrg O /oottqq4.C.('-. .-n*., hk..*
<br />q)lslalclxlNtElDAc-dcEllx
<br />I hcrcby lllrm utrder pcnoltt or Frjury lhal lhcrc h n conntuclion lc.dinB .8cncy lor
<br />'h.
<br />pcrlorMcc of lh. work for thich lht [tn.i h
<br />ksucd{Sc 11097. Civ. C.)
<br />AIIIICAXI-TIDI;I,A8AII!}N
<br />I hcrchydnmu cr r.nalty ofFrjury o.. orlhc rolk,wins dehrlii6.r
<br />Dcnb&t,n P6nns Asbc{d N.rifi.lrion R{cral Rc8olarbns (Tirlc40. Pan6)
<br />-Rcquircd
<br />Lrlcrol Norilrcalion
<br />l.c irr"ilrri rl'c f.dcrrlrrgtrhr()i\ r.tx'di'rg rsh.(o\ rcnn,IL xrc for ftl.rhl. r) ih'\ pnlccr
<br />ffimnllmffil
<br />rbove nE ioncd ptup.nylor im!.crion
<br />ricd.I asre rocomnly*irh rllCiryond C.unry
<br />i,csnturivcs oflhn Ciry ann Coun'y ro cnlcr urDn lhc
<br />Applimnlor/tg.nl Signolum
<br />Otn',//L 7.6.7o
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Founlains
<br />e igns (monument)
<br />Life Sale ty /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundino / UFER
<br />Torquerng
<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 />Ceilings (T-Bar Rough)
<br />Meter Release
<br />Rou gh 1/15,,/y '-t\K$
<br />Service lVleter
<br />FINAL h/4 /t,t 5(4
<br />Notes, Remarks , Etc.
<br />ELECTRICAL-INSPECTOR RECORD
<br />COMMENTS
<br />r,,,ru tu.,t * 8N { wCotS1fu . ,^r,*,
<br />trftlq'\ Addrc$
<br />Site-Work
<br />Transformers
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