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ELECTRICAL.INSPECTOR RECOHD
<br />APPROVALS DATE COMMENTS OWNER BUILI'ER DEI,CAiA'TION
<br />I hcrcby.lfiirn undcr p.illry or !.rjury lh l orcxcflrfl,mnrhc ConkactoF Licctr{ Ltrw ior thc lollowins rcev,. {sc..70115
<br />Blsincrs ! j Pofcsion codc): Any Ciry or G)unry whi.h dqutcs a Irrmir r. drn{rud. allcr, imProle. denhlish or qxt a.y
<br />irturrud, ior io irs tsu."cc. aho rcquitcs thc ,ptli.MI for sucn Frmir 6 fih I siSncd slaLmnl rhd h. or sh. is liccnscCr Purud'
<br />h rhc nmvhions ot rhc Conra.lofs Liccn*d Lrq (Ch4rdr 9, conmcncirs Nirh Sccli.n 7000 ol Divnion I ofih' Bu\i"( snd
<br />PmrcsioD\ Codc ) or rhrr h.orshe iscxenrpr rhcicli. Md lhc I'nsis ln rhc olhsc.t cknDrion. Anyviohlnrnols.cliorT0Sl.5hvanv
<br />nptli.anlforopcilnitsutjec(rhc,Pplic..rroa.i!ilp.nalrlornorntrc!hanlivehundrcddolla^(S5m)
<br />-l-
<br />ar owmr or rhc pn,tEny. or ny carPlor!.r wirh w,8cs as lhcn sb co pcis,(ion. willdo thcworkdd tlE smlm k mr
<br />inrcndcd orofcrcd for slc (Se.?044. Busincss Md Pmicssiotrs Cdc ThcCont0ciolsLiccnrcLjwdocsnoraPplyro.now.cror
<br />thc ForErry *b bn & or in!,ovLs ltEmn. ard w,b dms suh M,* himsclf or tcrclf or rhn,u8h his or hcr osn cnlk!)tcs.
<br />lrovidcri rhar such inipFkmnb m mr int nd.n .t oalcEi tor elc ll hor.wr. rlE h{ilding or in'Pn,w.tnr is sld wirhin om Fe
<br />.i.onlPlclion. rhc O]ncr Blildo wiu Mw t]. budcn ol pmviu lhll hc or sh. did ml huikt or nnpror rh. lm)pdv for rhc purli,* of
<br />-l,
<br />.s owner oi rte poFdr. im .xclusive,y .ont,acriru virh lien*d conracton ro onntud rtr roj.$ (SN. rol''t Bx{im(
<br />ad PioL*bn cldc: Thc Conlacru s Li.cn\. tr* docs nor atrly lo an osn4 orpropca, who t'uilds or nnpBvcs rncrcon.
<br />and wno conlE tslorsuthtmjcdswithtControclo(s) liccn*d pur\uanr lothcConl!,ct sLi.nrc tjw)
<br />I ncx.r.tr undcr SNrion
<br />UOBKEBI.q!}IITINIA.IION
<br />DECI/3AIUN
<br />I hcrchy alltrnuMcr penllryorperiury orc orlh. f{n[rwnr8 dccl$arions:
<br />I hrvc md will minlair a Ccniratrc or Conscnl to Scli lns!rc lor worktrJ ompctrsolion ds pmvidcd lor by S(lion l70o or th.
<br />tibor Codc, f6r rh. p.rforrona oflh. *ntt ror whhh rhc,,.nnil h tsucd
<br />-l
<br />huvc and s,llnBinr.in eorkcti conlp.i\.rion insurancc, tr\ rcquiredhyS.{rbn lT0Oollhc Lll}n Cod.. for rhc P.t{orroncc of
<br />rhc w..k Lrwhi.hthn pcrnrit is is$cd My wor*c^ ..nD.ns!ri,nr insurlocc crdfi d.d Flicy nunhcr &:
<br />-l
<br />enifyrhlr in rh. n nnrnunccoflhc *ort for *hi.h rhi\ ptnnil is hsucd.l shrll n rcnrllovaov lr.6on in,ny.runcr
<br />s, st) tr.om {hj€r ro rhc wortcrs comp.n$rion li*s olCalilnrnia, rnd tr!rcc rh ifl shouldtf,.om suhitl hltr
<br />workcis..mr.nsariotrrrovirion\orsdcrn,nlTs)ofrhctihnGn,c.lrh,l!.innhwirhconDlywirhrln,*prevkn'ns
<br />WAXNINC: Fail!rc ro ecum wortcrs' compensrn,. co!c88. h unhwful. lnd sh,ll .ubj.ct an cmllortt ro dninal pctrollics !t'd
<br />civil fincs up ro orc hundr.d rhousni dollas (SIOO.0OO). an nddnion lo lhc cos of smpcns.rion. dlm8cs .r p.olid'rl r{r rhc
<br />Sccrion 3076 ofthc Lah.r Cod., inlcrc( md atlorEr'r re.
<br />Appliotri:>(
<br />utExtEproNrlacrua
<br />DECLAAAIION
<br />I hcrch, dl,iimundo pcnalryol!.rj!ry lhat I am lic.hscd undcr provhion olChtpld 9 (commcking sirh secrion r0O0) orDivhi.n I
<br />of thc Busircs dd Pmr.sions Codc. Md m, liccn* h in full fora a cntcr.
<br />CONSTRUCTnN I.FNDIN(: AGDNCY
<br />I hcEby alfin, under Itn yolDcrjurylhal lhcrc hacon{ruLrion hndins lscn.y inr rh. pdfo,mncc olrhc*orl ror shichlhisPcrmir ir
<br />i$ucd (se 1097.civ c )
<br />APPLICANT OECI AR-ATIoN
<br />I hdrby dnmundcr pcnrlr, ofp.ijuryonc oflhc idlowins drhhrions:
<br />Dcm)lirion P. nnl^sbcslos Norificarioo F.d&il RrBuln'ionr (Tirlc tl{). PdO
<br />_R.quircd t rt.r olNorifrdion
<br />l.cnifyrhlr lhc fcdcal resnlrtions rcEardin8 asheslos rcnx,vdlm nol {ttliclt lc ro rhi\ pmj.cl
<br />rh!,!. r. rrrnal !olxrrtln, 'r1,.(r,,i Ir tx\.\
<br />,\Dplirut o.,1[$r sixnxltr,u X ,,," '
<br />r'**i,*r.* u"r, (
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Lioht Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab i Floor
<br />Bondinq / Groundinq / UFER lr t)41ufi ,/U\
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinos (Hard & Solf it Rouoh
<br />Ceilinqs (T-Bar Rouqh)-..r'r)
<br />It/eter Release l/t $rNtrlt
<br />Rouqh 6
<br />Service Meler I 2/1.1t41i lMeu)
<br />FINAL t)t4-zoz,) Js.s>ffi)
<br />Notes, Remarks, Etc
<br />4
<br />ID/SIG.
<br />D',k L
<br />Transformers
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