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ELECTRICAL-INSPECTOR RECOHD
<br />APPROVALS DATE ID/SIG.COMMENTS Owl\ER BUII,DER DELCNRATION
<br />I hc,.by lmrm undcr F.dlr, of p.rFry rhd I m.rc'nl)r hon rh. Con'mctoN Lic.ns L.v for th. louoeing tB)n (se.7Bl5
<br />Busin.sq Nld Piolcrsion Codc) Any Cilt or Counly whth rcquiEs o [f,mh ro onsttucr- nlrc. inp,6t., dcmlhh or rprn lny
<br />srNdurc. prior ro ns issuamc. also Equircs rh. lpplicanr lor such IEmn ro filc r riSncd sar.ftm rrd h. or shc is lienr.n ,,urs!nt
<br />b rh. lm,lisiinr or$. Conkrlor's Liccns.d bw (Ch.fl.r 9. CommncitrS Pilh Scctn'n 7m0 ol Divnion I ofrhc Busi.csl.nd
<br />Pmrcssi.ns Codc) or Ihll tr or shc is crcmrt ,Ecfron: lnd lhc born for Ihc rllcscd cxcmflion, Any violation of Sdion 7011 5 hy any
<br />lppli.anI for a p.nnil subjels rhc applicur to ! civ il FnBhy of nol mrc lhln fiv€ h!.drcd dollrs ($5u))
<br />Pi. * orrcr or rhc pmpcny. or ny crployc4 wirh wus.s ,s rhcir sL comr.nsar ion. will do rh. wod{ xlIh.slfl.1e isn,
<br />inrctoLd or.ficrcd f(* $lc ( sd.?Ot4. Busincs Md Pmlcssi.ns Cod. Thc Conkrclols Li.enE liw des nor ,pdy h ownd ol
<br />rhc loltrly uln huilds or inrreBltrr@d aod who dms *h M* hit.cltor hft€lfo. rhrcuBh his or hcr o*n cmptrrfcs,
<br />povidcd rh(r such in rmEm i e rcl inrcnd.i or olterld nn eh lt h'k!u, rlr htildin8 or in{mrmnt k sld *irhi. om FU
<br />or sftrllirn- rrE o',nd Buitk will h,rc rlf hrd.tr of pmvins rhar lE or shc dil 'u,r btriLl u inpiow rtr pmFiy for tlr !u.II c of
<br />-!.
<br />as o{rc!oIrhc l,opcny. amcichsivclyconrrucrins *irh liccnscd contr,cl.N kJ.orslrucr rhr pmicl (S(. 7044- Bu\ilcs
<br />nnJ Pn,f6siD Cod..l hc Contrt sLi.cns.Lawd.c\.orrpplyroanowmroipro|rrrywh(,bxild\oinnPtuvcsrhcrcon.
<br />rnd who conlrucrs lbr such ptr,Jc.( Nirfi ! Or rucr.($ licorsslru^or r k,rhoG)nlr.crols Liccnsc L1q)
<br />-l
<br />omcxcmpl utrlcr S.di
<br />fd:dl)o"., .1'22')-8 u*,..-)(
<br />DECI,ARATION
<br />I h.rcby amrnudcr r.ahy of pcrjlry 6nc 6l thc tollo*ins d6ld{io.sl
<br />-lhavc0rdrillflinrlin!CcniticlrcofConscnlroSclllnslrcforuorkc*
<br />onpcnsrion. os pmvidcd for i,y Salion.l7{x) ollh€
<br />blrr Cod.. ror rhc Frrolmrc olthc *o* for which thc pc.nit h hsucd
<br />-l hflvc antl will nr.irluh ,orkcr' c,mpcnsltn,n inruBrce. !r rcqxircd by S.c! nr 1700 of rhc Labor Codc, ior rhc p.rforn@c .l
<br />lhc work for which lht p.mit ii issEd. My workcfi onpcnerion insuranLt cari.r i policy numb.r ec:
<br />knicy Nutr$rr:-lixnnc\
<br />@ltFrir-" rr,nr ,n rl'" ra*nunccofrhc *ori rbr *.hich,hi\ pcrrir is i\skd.l \hlllnot c lplLJynn! |x^fn inrn, Doncr
<br />v, srohconrc \uhJccrlo rhc aorkrs .o,np.nsrnnr hwl ul Cnlifrrnin. aftlr!rcc rh{t ill\houl hc.onf, \uhrl{ k,t)f
<br />workc6'cnmoctr{arionnro!i\t,n\ofSe.ri(,n.lTmolrh.tnbitrc{xlc.ldrll.li,nhtrlthcrnr,rlywilhihospx,vi\iurl.
<br />WARNING r{ihtrc lo wurc *orkcis conDc.sari,,n covctr'sc i{ oilawtul. dnd sh,ll subJc.l an cmplorr lo .inri.al Fnrlri\ nnd
<br />ciil fincs ur lo onc hundrcd lhousand ddllu^ ($100.0(x)). in u{hiri.n ro rhc.os ofconD.ns0li.n. d!ro3c\ * providcd rd fi.
<br />S(nun.10?6"irhc L!t-r C"d.. inrflrr 3nd u trr'\ r.crz_-\
<br />o,", /€ :2) \Yn*,,-*, d /.-. o--rz-...o. r\ \S<l
<br />LICENIiELCqNEACIAf,
<br />DEgI.Af,AIIO!
<br />I tcrcl,y amrnundcr pcnalryofFrjuryrh,r , nn lirn$d xndcr povision ol Chiptcr 9 (onrmming sirh Sedi'n 70001ofDivnion 3
<br />ol lhc Busircss ond Prcfcsions Code- and my liccnsc t io l'!ll ro@ d'd cffc.r.
<br />ConrmdDr:
<br />CONEIAIJCITQNIEdUNG.EGENII
<br />I h.Eby amrm u.dcr l.dlry of Frjury rhar rtm n a connddion lcndin8 agcrcy fo, the ncrfotrr1:@ of rh. wrt for uhth lht Fmn t
<br />htucd (s( 1097. c'v c,.
<br />AIfLICAII.DICLA3{IIN
<br />I h.Etry 0finn unds rnall, of ncrjur, om of rh. lollosins dNldrrionsl
<br />o.rmlirion P.rnits-Asb.(os Nolificarbtr r'cderal Rcsul0ri'n.11illc:10, Pd6)
<br />Rcquircd lx!icr of Nolifrcalion
<br />_l ccnilyrhar rhc tcdclr I rc8u br n,.i ftgrdin8 Nlri.x r.nn,r,l ,rc .ol lpnlic$lc ro rhis nmiccr
<br />*#rirylhar I hrlcicndlhi\ lplli.alionn stalc lId lhc trh)vc inntr'lrri,, i\.nft.r lrtrLrro.omflywirhnllCiryrtrJCounr,
<br />\ rid Sric t]ws rl.rirE h liuildirs .onnrudion. .nd h.rc$yrurhoriTr 'cpr.\cnrdilcs olrht Cii! rtrd Counlylo ctrrcr trF)n rif,
<br />rtxxa mrnrbicd p()ILdt for i
<br />Appli.ml or s.nl sk.nlurc
<br />""*r"" *,r. , rnnr,, K
<br />_rA*E><l ,'", 5'?lk
<br />-r\c,r,-\Cj Atc,:-lxl
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Sions (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 />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soflit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />Rough /;/1/ts, SYt
<br />Service l\/eter
<br />FINAL {/ | /lr )r \<q
<br />Notes, Remarks, Etc
<br />lt/leter Release
<br />t;a-*k
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