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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE rD/stG.COMMENTS OWNER BUILDER DEI,CARATION <br />I h6eby amrm lndd p.nilly oa psjury thrt I m .r.mfl lof, rhc Contraclon Lic..sc hN for rh. folLwirS r@. (Sd.70l L: <br />BGi.6s a.d Prof6sion Codc) Any Cny or Counly which r.qut6 r F mit lo coddd.t, ah6. improvc d.molish or r.!at a4y <br />strudu.. <br />',rior <br />lo n! isudca ale rcquic lhc appli. l for such perfli[o 6lc a sis.cd nd.m.. rhar h€ or sh. is lictucd pu*dr <br />lo rnc rroyisioN of lh. Conradd ! Li@nsed t r (Chaprs 9. Comdcin8 qith Sdion 7000 ofDivision I ofth€ BusinN Md. <br />Pmf6siom Cod.) or rhar ne o. sh. is eicopt lh6eftoft dd rhe b6is for thc allesed excmprion. Any violario. ol Sdlion 70.r I .5 b, sy <br />Nffi;'*;ffiffi d;-ffi ilffi dffi :I#il1'",1-., <br />rh. pNpsly who builds or inprevEln6oa and who do6 sch w* himsclt or h6clf or lhmlgh ht or hd ow. mplorc6, <br />prcvid.'l lhal sucn imporada e d inlqid orofisld foreG.If. ho$6d. $. toildine or impnvoEnr isFE*nhhoncl@ <br />oicompletiotr lnc O$nd Buildd wi[ h,!. ih. htrd6 oaFovins rhd h. or sh. did Nr hild or nnpror. lh. popar, for ttc pupos ot <br />-l.6owoq <br />oflhc pmpsry. m dcluiv.lyconlrrrin8 silh licm.d conrmcloB to conslrud lh€ !.oje.t (Sr 7044. &Bms <br />Md Aof6si,n Cod.: Thc CDntraclols Licosc Law do6 not applylo u orna ofprop.ny who builds or lnprovcs lhdeon, <br />and who onlds for slch Eoj..rs wirfi a ComBdo(r lttr d lu6trr torhcConr6ctois LiccM L{w) <br />-l <br />m er.mfl unds Sdio <br />qIITABAI!)I <br />! hercby aflim uodtr p€nalry ol psjury one oithe lollo$iry d(ltr.lioNl <br />-l <br />hav€ and * ill mintain s Ccnificatc of Cotucnl ro S€ll-lnsurc lor uork.*' conrpensrion, 6 rftid.d aor by setidn 1700 of rhc <br />tabor Cod., for the p6iom ccofthcwort for which lhc paoil is issu.d. <br />_l haw and w,ll nainlaio wdrke6' conpeEalion iNulancc, 6 r.quted by Sed ion 3 700 ollh€ l.abor Codc- foi rh. pdfome.e ol <br />rh. r'ork lor which this pdir 6 isd. My worlds' comp€Nrion iEuacc @is ,nd policy numbd d.: <br />Poli.y Nuib6:-Expt6: <br />I c.nify rbd ir thc psfo,iMc. of rt. *ort lor *hi.h rhi Fdir i! isslol.I shrl nor dploy ey p.Mn in my malffi <br />$ 4 lo bcoh. subjcr Io lhc vork6' comp.Gar ion laws olcslilonia ud esr€c rhal il I should b..onE subjdr to <br />'h.worl6 comp@tion pdvisios ol Scclion 1700 ollh. Labor Code I slall. fo.rh*ith conply $ith lhoe povisioo <br />WARNTNC: liailurc to seur€ NorkcE compdsarior covoag€ is trnla{tul. atrd shall subj(r o,ploys h rirniml [hahi6 tud <br />.nil fir€s !p ro onc hudEd rbo@d dou6 (tl addnion ro rhc cosl ol conFerion. d@s6 a Fovid.d for lh. <br />sslion 10?6oflh€ Ljbor Code inlerBl and fiomey <br />I neruby ainm u.dc. pe@lty of pdjury $al I d I'csa.d und.r Fovision ofchaDtq I (connmcins * nh <br />ol rhe Busins d t'rofBsioB Codc. ednylicsc is in fulllorce$d€rd. <br />CQNIAIJEIIO!}DIDINGICTNCI <br />I hftby amrm undcr p.nalty olDqjury Ihar rhm is a @nnrudion lddins asocy fu rhc psfomncc of rhc vort to^vhich rhir ldnir is <br />isu€d (Se.1097. Civ C.). <br />AfIITCANLDECLAAAIIAN <br />I hcdry.,!nn undd poahy of p€rjury oflc of lh. louowirg deltralioNl <br />Dmolnion Pmirs-Asbclos Noti6dion Fd.r.l R.grlarioE (Tirl. 40. Pd6) <br />J Rdutr.d ldknrN.nidhr <br />_l coriry rhal thc tufrI r.sul,lioa cs&dins sbGros rmovrl rc nor applicabl€ to lhis pmj€n. <br />*.*^, <br />F..r-*.*,"a <br />na st0r.rhdihcahr\. inaonndiotr h.oddr larre b compl, wnh all Cilyand Coun'y <br />alhk City md Couly ro olq lpod dF <br />*,{Lt-//-6.lmvc Mr nrd tropoly lor <br />A rlicr r o.,\gut Si8n{rur. <br />coNtudion. lxl hd.by aurhori. rcF.srar irs o <br />Site-Work <br />U ndergrou nd <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 />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Transformers <br />I. rqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilin gs (Hard & Soffit Rough <br />Ceilings (T-Bar Rough) <br />Rough <br />Service Meter <br />FINAL a/o/t ./,-/VUl'. <br />Notes, Remarks, Etc <br />Meter Release <br />411 <br />""'la#y'a <br />I