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ELEGTRIGAL-INSPECTOR RECORD
<br />APPROVALS DATE rD/srG.COMMENTS Omd Blildq Delmtim
<br />I hdcby aflim undd paalry ol pdjury d'al l m cxopt fom thc ConreioB Li@* L.w for lh. following tfton (sa.703 1 t B6in6s
<br />and Prcfdsio Codc) Aoy Cit, or Cou y *hich cquirG ! p6mi to c@sb!ct, rltd, imp@v., ihmolish or rcpai My slructu.. Fid ro iI!
<br />issudc., also r.quiB rhc lrplicet for sucn pmn ro iil. . li8n.d it tmat $!t h. e stu is licds.d psuur lo th. Fovisi@ of 0E
<br />Contraciols Licos.d Ldw (Chapt r 9, Comhmcing wirh SElion 7000 of Division I of ft. B6ii6 ed Prcf6io! Codr) d rh{ h. q
<br />sh. is.xmpr drrcfror ed $. bair fo ihc rll.gcd cx.mpli@ Any violaiio of Salio ?031.5 by uy applicdl for. p.mn rub.jet 0'c
<br />appli@l to . civil poally of no{ norc th& fiv. hunded .lolla (ltoo)
<br />_I, a ownd of th. troFny, or my mployc wnh w.ad 6 rh.t solc @mp€nsdion, will do $c wo,k &d tlE slruclR is not inhd.d
<br />or oficrcd fd salc { Scc 70/14, B6ine ud Profsions Cod. Tl. Conlmcior's Licdsc L.w do.s nol alply roe owod oifi. propdy
<br />who builds or improvB lhcfu., dd who dc such wo* ni@lf or h6crl d rhr@gh hir or hd o*n cmploy6, provid.d th3r such
<br />imprcvn.nG e no( int ndcd or ofi.rcd for ralc Il h*cvd, $. building ( ihprcvddl is 3old wnhin onc r@ of compl.ton, $.
<br />Ow.d Buildo eill hav. ih. burdm of provinB lhal hc o. sh. ror bnild or improvc fs th. p{rlGc of sal.)
<br />_1, a owna oalhc propcny. m.xclsiv.ly conFo.lin8 with liccnscd conr&toE lo cosLuclln. Foj6r ( S.c ?044, B6in* dd
<br />P.of6sio Cod.: Tnc Contr&ld s Li6* Llv &6 nol lpply to 4 oM., ofprcpdy who builds d inprov6 ihd.on , ed who
<br />contr&ll ld such projcds wnh . Conb&to(, li6s.d puEuet ro thc C@tacor\ Li6r. Law )
<br />I o.x.npt undcr S.crion ,B &PC folnhrcEon
<br />WORI(ERS COMPENSATION DECLARATION
<br />I h.eby alnm undc, poalty oa p.rjury o.. ol th. lollowinS dalMdotu:
<br />I havc sd will Minliin a Ccni6st of C@at !o S.lfiNlE for wot 6 comp.r$ii@, 6 pmvid.d for by S.crio. 1700 of rhc
<br />Labor Codc, for thc pdfmMe of fic *ort for whicn $c p.mir is i$ucd
<br />_lfiavcedwill mlinLin wnk6 Mptralion insu6e, s Egutcd hy Scclid l?00 of lh. Llbor Cod., lor thc pcrfmec. of th.
<br />wo for whi.h rhis pmn is issucd My wd*6' omp.nelion insurue cMid ed policy numb.r d.
<br />Policy Numb6:Jxpi6
<br />(ThL @io ned nor b. cmpl.Ld if $. psmir ii am On. hm&.d dollB {l l0o) d Ie,
<br />I c.nily $.t in lhc pafomocc o{ dc *orl fd *hich this l.mn is issucd, I shall noi cmploy dy F.d in &y lMnd so s rob.@ subj.cr |o $. wqk.u ' mmpasation lavs of Cxlifmid. ed ag@ lhd if I ehould be.h. subjd b lh. war6'
<br />conpdsation prcvisions ofs.clion 3700 oflhc Lator Cod., I shall, lonhwidr ffiply witt lh6c Fovisios.
<br />5-rZ,/a./-/.
<br />WARNING Failurc to r.cuE work6 cmFnerion covc.ag. is unlawful, -d sh.ll subjet d oploycr to 6inin.l poultiB ed civil
<br />finB up lo onc huhd,ld ihocmd dolla (t I00,00o),in .ddidm lo t6. cGt of composrion, dmraB 6 provirlcd ao, O. S.ctiM 30?6 oa
<br />thc Labor Codc, inld61 ud artm.y's f.6.
<br />ucEltEpcotrrMcrQBtpEgaBArIax
<br />I hcrcby 5frm und.r p€nally of pdjury lhd I M lim.d und6 prcvisio oa Ch.pld 9 (onmadf,8 wilh Sction 7000) of Division I of
<br />thr Alsif,ds od Proi6im! Cod., od my lic6s. is in full fq.. md.if&r
<br />CANflAUCIION.LIIDnIC,AGINCI
<br />I h@b, .frim un&r pa.lry of pdjury th.t th4 b r @6L@lioi lcndiig agd.y fo thc p.{mecc of $c wat fc which rhii p.mn ij
<br />isu.d(Sa 1097. Civ. C)
<br />AIILICANII9EEIAAAIIOX
<br />Dmdnion PcmiB-Asbdiq Notificrtion Fcdml R.gul,tions (TnI.40, Pan 6)
<br />R.quir.d Lcitcr of Notilicilion
<br />_l ediay rhat the Gda.l rc8ulations rcgardiog abBl6 r.noval dc ror appliqbl. to this prcj.d
<br />I coniy lhat I havc r.!d t}is appliEtiq md stat€ fiar th. abov. inam.do. is mcl I l8rc ro omdy eirn all City ed Conry
<br />ordindc6 dd Sl.lc La$ .elatiog lo buildiie consElclid, ed h6cby adhorizc Ep6.nl.riv6 of $is City ed Counry lo dld upon lh.
<br />abov. m.n.ion.d piop.d, lor instetion purposB
<br />/Z.--Dak ----4
<br />-$ ea-,,Z->c4 .
<br />-/o/
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torquing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rough
<br />Ceilings (T-Bar Rough)
<br />F\r6iE trl
<br />Rough
<br />Service Meter :ERNI
<br />FINAL
<br />Notes, Remarks, Etc. sAItlG LrF+r' tvr' rw;uE.'
<br />Site-Work
<br />Under Slab / Floor
<br />Meter Release
<br />c6d
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