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ELECTHICAL-INSPECTOR RECOHD <br />APPROVALS DATE tDistG.COMMENTS OWNER BUII-DER DALCANATION <br />t hcrcl,y al6rn und., pcnahy r)f ,rcrFry rhol I d .x.ofl tn,m rhc Co rack,6 Lic..sc tiw tot lh€ lolLwine rcabn (Ss 703 I 5 <br />BlFiturs rnd Pror.sn,n Codc): Any Ciry .r Coum, which tcquires 0 Fmii ro conslruct. ohe.. imirovc. d.mlish or aran &iv <br />srtu rurc.riorro ns issuMcc. aho mqutesrhcapplicanl for \uchnemir ro filca sismd shrcftnr rhxr h.or shc is liccn\cd pusun <br />ro rhc lk,lnions or tlf, Crotrt&rois Licc.s.d bw (Chstlcr 9. CommriiS wilh Scclion 7(x)0 of Divkion I of rh. Bbinds and <br />PmrcrsbnrCodc) orlhlr hcorrhc h cxcnrpr lhcrcfrommd rhcbosn tdrh. rllcScdcremllb. An, violarionorSccri,nToll5bv anv <br />aprlic!trr ior r lcrn sbr..h lhc ttPlicanrtoacivilPcnahyofnorm.erhrnnvchlodrcddollds(5500). <br />El. i\ owis of lhc |mr.nr, or iy cmltortcs wnh s08cs us lncir $k mqxnsdrion- willdo ltr *dt and rlE dtrtw i\ mr <br />; endcd or oiler.t for sl. ( se 704,1, Blsims and Pn)tc$nrns codc l-he Conrd.roar Lkcnsc tiw drcs nor upllv ro an owrcr .t <br />rh. rmFiy wh. boilds or i'nprB rkrsn. dnd who d@s such rc* hims.lror hcsclfoi lhmush hn or h.. o*ncmPlorcca. <br />providcd lnll such in{,rovcftnrs m m! inrcndcd or ofrcrcd for sk lt rbscrci E toildins or irymv.m h$ld wirhinon. rtu <br />orconnhlio.. rhc Owncr Blildcr will hnlt lhc hudcn ofpmvins rhd nc oi shc did nol t iU or irymh rhc pDtlnv iorrhcptrrPe.r <br />-1. <br />asoqrctofrhe pmpeny. dmcxclusivclycrnlBcri.g *irh lic.nsd conr0dor lo flr{nd rtE Ptuitt (Scc 7044 Busm$ <br />rnd It rGsionCodc:ThcConlrackn'sLicc.scLowdocsnotq,plylorno*ncrofPml)crty*h.boildsorimlmvcsrhcrcon. <br />and who 6 n h ror such pr.irrs wirh r Conr&ro(O li.cnscrl pulrEnr ro rh. contmdor's Licnsc kw). <br />_l a,ncrcnrnr uMcr Sarn ll <br />'cl trfr (u-.".X <br />DECI,ASAIION <br />I hcruby {ftirn DMcr p.nall} of p.rJury om ol tl'. lbllowinE dcclmtionrl <br />I havc lrl will mi.rain o Clrl iiE|l. of Consenl ro Sclf l nsuc r.r wo cs @nqs.sriot s pmvidcd tor bv S..lion 1700 ollhe <br />Lnb.r Cod., for thr pslormtra ol rh. Mlk lor whth llrc !.m n isslcd <br />-t harc lnd will roinhin {o.kcm compcnsrrion ins!6tu., is r.quiEd by S6lioo l?@ of rnc bbor Code. n/ th. pcrforoGc or <br />lhc work fr vhich rhn Fmir ii issxn My work..s' mnqEnsrion insumrce cdtfurd l[lay numb€r 6cl <br />U l ccn ity rhd in rhc rcrformrcc or rhc *ork ro. *hich rhis D.rn r t t\ucd, I shull nol cnploy an, p.rson in an, maner <br />$ asro bcconrc subjecl ro rh. soiks compcnsarion laws ofculil'ornio. sl(l aBEe rhd if I stFuld bccotm subl.d ro lh. <br />wolktri compen$rion !tuvisions of Sc.lion 3?00 or rh. tjbor Cidc. I snall tonhsirh orPlv $nh l,Es pmvkio.s <br />WARNING Foilxrc ro sccuE *ork.^ .on1F,nsllion orcEsc i\ onltwtul. ond shlll \uhj..' nr' .mlk')tr l(r dinintl l)co lics and <br />.ivil nncs up to onc hundrcd rhoussnd doll s (SIOO.(X)o). in rdnirion ro rhc co( o, comp..salion. damgcs as provid'd r'or rhc <br />sc.rdr 1076.l rhc Llktr C, c. i'ncrci rtrd tonrr's fccs <br />""," <br />. t,ltlt(lppricanr:ts <br />DBCI ARATI(}N <br />I hcnhy !flnm undq p€natryofp.tjury rh l am licnsd ud6 pn,vision of Chlprc. 9 (onmtrins with Serk. 7fiD) ol Dilhion l <br />or rhc Busimss otrd Pofessi6n3 Codc. a my liccns t in ruu toft tu l cfiect <br />CoNSTRI]CTION I FNDING AGENCY <br />I hcehy affim: undcr !€nllryorp.rjury lhar lhcrc h a con(rucrion knditrB usc..y ttt th. pcrformotrcc otrh. wo.k for shich rhn Fmir <br />'shrued (sf.. 1097. Civ C.). <br />tfndtr ( Addrc$: <br />- <br />APPLICANA D}'CI ATIAT!(IN <br />I hcrEby lnimuodcr pcnrhy of pcrJury onc ofrh. follosi.g dctltrtrlio.\ <br />I)cmolirion P.irnns.AstEsros Norificdi fcdcnl Rcgohtn,n\ (Tirlc.rll, Prn6) <br />_Rcqutd brtct of Norif.alirn <br />-l <br />ceflify rhar rhe lcdcm! rc8ubl ions egtrdi.S ssbcsos rcmvd are nor trpplic$k to lhis Pmjccl. <br />Ul ceniryrld I h,vc r.ad rhis aPdicarion ond slarc rhsr $c atnvc informiion iscordr' I agft rosnDlvvirhlll Cirvand Counlv <br />6rdao,re1 r,rd Srarc t:*s Ehing ro boildi.8 consrru.iion. an lEeby tuthoriz rcF€e.rdriws ol rhh Cilv .Id Counlv lo cnls lFn rlE <br />rhivc trrnho ctlt'o|{ny li)r iNpccrvAppliunl o. .{gctrl SigMturc <br />t tnrilec nnnnrn;nrr: *-Sfe."^ !1"^,"r <br />-". (,1!+{ <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Sions (monument) <br />Life Safety /Low Voltage <br />Fire Alarm i Dampers <br />Communications Cable <br />Buildanq <br />Under Slab i Floor <br />Bondinq / Groundinq / UFER <br />Transformers <br />Torqueino <br />Sub-Panels <br />Air Conditioners <br />Rool Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Solfit Rouoh <br />Ceilinos (T-Bar Rouoh) <br />Ivleter Release <br />Rouqh 6"271V XU-,{.)lU <br />Service Meter (r <br />FINAL 1\\l\fl ^dltAG)Notes, Remarks, Etc. <br />-a <br />Policy Nu.rlEr <br />-Erpnc(: <br />Li.cnsc Chs: Li.cnsc Nunrbcr _- <br />Dor? - ('onlrucinr <br />fT <br />I