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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS O\{NER AUILDER DEI.CARATION <br />I h@by amm ond6 po.lty of pdjury lhal I m acmpl from lhc Conradon Lic@ Liw aor rh€ follo*in3 reen (Sc.7031.5 <br />ausinBs ad Prolsion CodG): Any Ciry or Colnry *hkn requnB r Fni lo coDslrur1. alls. improvc. doolBh .r rcFi. @y <br />slructue. pflor to irs issu c., 0lso rcqut6 lh. spphcml for such !.mil lo 61. a slgi.d slaldnot lhal hc or sh. is lics.d PuM,l . <br />ro fi€ provisioN ofrh. contleror's Liccned riw (chaprd 9, comndcins wih sdion 7000 olDivisioo ] ofrhe BNin* dd <br />Pof6io6 Codc) or rhat nc or she is .rdnu lfid.Gom ed li. bssis lor Ihc allcr.d q@rrion. Any violatio. of Sation 701 I 5 by &y - <br />applicanr lor a pmir subj*B rhe appli.d ro a ciril p.nahy o anor horc lfie fiv. hundr.d dollds ($500). <br />t, 6 oMd oath. Eop.ny. or my .nploy6 sth wa86 4 sl. cohp.Gatio.. will do lh€ wrt ad thc sltucl@ 6 ml <br />i dr{l.d or ofi6€d for elc (56.?044, Busin* dd Pofeiotu Cod.: Tn. co.ltelors Licmc Llw do6 nol apply ro & oMd of <br />th. lopdy who buildeor imprc!6rh@n. md vto do6 $'chw or h6.ltor rhmogh hir or h.r oM.nploye6. <br />prclid.d rhat such ihForffits emr ddd.d o.ofidal for el. !t howds.lh. hildiog or hrprov.lr6i is $td wirhin un. ra <br />of co'npkrion, thc O*Ts tJuild6 vill havc rhc buds of pmving $d h. or she did ml boild .! imFovr lh. FsFty ror tE Fnlb* ol <br />l. s om.r ofin Fopsry, m conrraclins wih lic.ns.d .oirado6 ro coElrd rh. Foj..l (Se. 7044. Asi,6 <br />@d Pror*ion Codc: Th. Conrracloas Lic€nsc Lsw do6 not apply ro d omd of propdy wto builds or imprcv6 lh€r.on. <br />.nd who contracls for such Foj€1s with a Cont .lo(, licoscd pu6wt lo th€ Conrraclor's Lic@ t!w) <br />I anexe'nd und6 socrio. ,a &PC lorlhisreson <br />i)8rcr Orn.r <br />IIOBKEBIICOIiIEEIIAIIOX <br />DECI.AEAIIO! <br />I hd.b, aflirn und6 p6ahy oaFjury onc of rhe folloNiq dElearioB: <br />I havc a'd will Mintain a Cdificate of CoBm lo s.lfiBur. lor rort6 compssal ion. 6 providcd for b, Sdtion l?00 oalnc <br />Labor Codc. for rhc Flodecc of tne {ort aor snich lh€ Fonn is Gu.d. <br />I havc .nd will naintain workcu' conDcNalion insurance. 6 Equned by Sdlion :1700 ofinc bbor Cod., for lhc psfomdc. of <br />thc mrk for *hich lht p.flril is isucd. My *ort6 conpccalion ituue.c .mir ad !.licy tuobq dcl <br />c*t-, &I$!d (t'^ 4"ra^ ) r,-,r <br />lz 4{l rlz;x <br />I cenrrylhat in lhc pnfomance of rh. woik for which rht pdrnit G issucd, I stall nol @ploy dy p.Nn in an, nmnd <br />e 3 to bdo,nc suqd' ro th. wort6' comFE lion las olcaiitooia. dd aeta ln{ if I should b€con€ subj..l lo lh. <br />voll6' compcnsalion prolisions ols€crion l?00 of th. I$o. Codq I sMIl, forlhrvilh compty *ith lho* previsioc <br />WARNINC: Failurc ro src rorlm' cosFMlion occraBc it unLvtul. ed sh.ll subjst M mplord to qininal pssXi.s ud <br />civil fincs up Io o,c hmdrcd rhousd dollm ($100,000). in addition lo lh. cosl of, dm.86 6 Providcd lor lhc <br />.z/ r <br />Labor Cod.. i,rdd dd alloflEyt lG. <br />t)lzot: <br />PECLABALION <br />I bEeby alttrm undcr p.nalty o I pajury lhat I m lieilql lMd provilion olcnapld 9 (com,nqcins wilh S.dion 7000) of Dilirion l <br />oa th. Busins ud PrcfsioN Codc, dd ny li.c6c b in tuU torc md.fid. <br />lozu 3UQ <br />2--">.-"-.{p!vuroolr:xaJr [e/ <br />CONSTRUCTION LENDING AGENCY <br />I n@by artrh unds Fnahy of psjury $ar lhft ! a conntoclio. hnding ag6cy aor ln€ pqaommc. otuhc ert lor whi.h thi! Fnir t <br />iss!.d (sc. 1097, Civ. C.) <br />APPLICANT I)ECI,AiATION <br />I hatiy afi'nn undd paahy of pajury o.c ol thc foUowing dele.lions: <br />Demohion Pmil!-Asbdros Notificalion lcddal Resulalions ('I irl. 40, Prn6) <br />R.quired Lctts of Notifir,tion <br />I csli& that lhc f€dsal resulatioN rcB6di.r dbelos roov.l d. nor aPplic.blc Io lhis Prej€6. <br />ili rh,t I lts\€radlhislpp li(arion dsrate tlmt rhc abo\c | oBre ro corrplywirh allCiryand Couniy <br />ordinlnc6 dd sror. La*s ElatinB to buildinB <br />abovc notioned pbp6r, <br />Applioni or g.nt Signr ::"Kd <br />o 2.r7) <br />Site-Work <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 />[Jnder Slab / Floor <br />Bondinq / Groundina / UFER 1 ,1 -?.o Drknaor tE7 <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment n i)A^n,n trs1 <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soffit Rouqh <br />Ceilinqs (T-Bar Rouqh) <br />lvleter Release 7{2 I)Nm.n KE7 <br />\T <br />Rouqh <br />Service lvleter <br />FINAL /D&,^4 n_fr 9 <br />Notes, Remarks, Etc.I <br />-+ <br />Rev.08-07-2015 <br />2r) <br />L \11)