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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG. <br />Unde rground <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 / Groundinq / UFER <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Facto ry Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soffit Rouoh <br />Ceilin gs (T-Bar Rough) <br />Meter Release <br />Rough <br />Service Meter <br />FINAL ma Y//il a {#rt I <br />Notes, Remarks Etc I <br />OWNER BUIt,DER DELCARATION <br />I htr€by amnn tr.d.r !..!h, oa pojury rhd I d .r.hpt from thc ( ontd.loft LiceNe La* lbr the lollorvins rcen (5(.701 1 .t <br />Insin6s lnn Profsion ('od.): Any Cit, or Counly *hich Equn6 , tnn( ro .snntucr. !lrd, inpolc, darelish or klatr ey <br />struclue prbr 10 ns isuucc. atso rcqln6 $. applker lor such lEnni ro 6k a sieial srdmr rhd tu or sh. i licd.d puu@r <br />ro rt€ prcvisioB offi. contractois Lic.ns.d Lrv (Chapto 9. Conmdc'ns Nilh Sc.tion ?000 oa Dnision :l of rh. B6in.ss dd <br />Prof6sions Cod€) or lhal hc or she is d€,rpt da.nom ad thc bdb for rhe all.aed dmprio. AnyviolarionofsdionT0ll.5 br 0ny <br />aptlicanr forap@ir subjdtsrhc applicg loacivilp.nalryo|nor morclhan 6v€ hun&cd dolltrs ($500) <br />_1. a o\q6 of the FoFny. or my cmplotcs $ nfi $.96 6 lh.n $b ..trrp.Mion, sill d. fi. work md rh. sMm is mr <br />intori€d orof€rcd fo, elc I Sc.70tl4. Busins ed ttolsions Cod. I he Conlruclor's l-icas. tiw do6 nol apply lo an oM6 of <br />lnc pFpqly who buil& or imp!!6 dEaE ad wbo do6 such srk hins.lf or hd.lf or rhmnsh hh .r ho oM .mployts. <br />provided rhar such iinprovoMc m mr im5d.d or offdcd tor elc lt hoNod. lh. h{'lding or imlrov.]mr i! $ld wirhin one rd <br />.fcompl(rn( rhc Os!6 Build6 wiu hat l& hu&n ofFovin8 lhd h€ ot shc dil ml &ild or impmvc tnc proFty for lhc purpoF ol <br />-l.6or'.crorlhc <br />prcp61y. m cic lusivcly .o nlract in s wilh licmsd conlmcloBIo conslrucl th. Irojcl (S* 70.14. B6ns <br />and BDasirn code: Th. (in ractols Li..n!c l-aw do6 nor aptly to o o{nd o I propdry who builds or mprov.s rhdsn. <br />dnd who conlEcts for su.h pojecls with a Conlndo{s) lic.ed puurat b th. Conlracx, s Lic$e t w). <br />! m.rmfl n6do serion_, B. & P.C. lorthis r6on. <br />Drre: O*tr.r: <br />]laBf,l:&Ll:olltExs ra! <br />DE(IAIAIIA! <br />I hd.r, aflim unds pdalr) oa pqjury on€ oflhc followinr d(ltrarions <br />_l havc od will daintain a CcnifidcolcooHt to S.lf-lnsurc for workdr an$ens.rion, * pmv cdforbySdrionl?00oIrh. <br />lrbor C.de lor lhc Ffonnuce o t thc worl for vhich rh. psnil is (gued <br />_l ha!. a.d will mai.tain work.ts comp.carion iBuEn e. a .equi.d by S*r ion .1700 ol th. tibor Codc, lor lh. prfomdc. ol <br />Myworke6 composalioa insurmcc c i6 dpolicynumb6s.: <br />-l <br />c€nirylhal in lh. prfoflnanc. of (hc work lor which Ihis pdni is i.s!.d. I shall nor dploy.ny p6on in m, m&nd <br />$ dto b€cooc subj€cl lo lhc wolt6'ompsE liotr l.vs ofcalifomi& ed,Ar rh.l ia, should h.com. subjer lo lhc <br />*0116'coipcelionp,orisioNolsdionlT00ofth.t hor Codc l rDll, lonhrvith conply wilh thos provisiotu <br />IVARNINC liaihrc to sure *ork6' comp.Narion .ove6ge is u ld\!aol. Md sholl srbjst M onplorc ro dinrinal pdElti6 and <br />cx'il lines ur lo on. hundrcd lhousd dollm ($100,000), in addirin <br />'o <br />rh. cos ol.ompoEarion, damec 6 plovid.d for lh. <br />Code, i dd &d rormy s fs .B"z/y ,z---. <br />r,iir::rir;rr r orr rrr,i.rriil <br />DEOd&flO! <br />I h@by amrm und6 p€nah, olpdjurylhd I m licmsol undd Fovision oachagd 9 (commm.inB wirh Sdion 7000)ofDnision 1 <br />oi thcB0sindsed Pnilis$nsCod., dd n,! I'c0\r is i', tull nnc. Llcfl..r <br />colLgBucuoll,EtDllclc!!(I <br />I hftbt aftrm undd poalry ol psjury th,l lh6. ie a odtucrion lodinB a!@y for rn. pqfollr@. of thc work for ehicfi lhis Fnn t <br />issu.d (Sd. J097, Ci! C.). <br />atfl.tc .NLD[ctaa uoN <br />I @y arfim und6 p€n.lty olprjur)' one of lh€ lollowinB drla.tions <br />D.molilion Po'mils-Asb.slos Noli6crlion Feddal R.rul iois{Tilt40, Pd6) <br />-Requircd <br />Ir(d olNorincorion <br />,\t,pricxnr o, ,\s.tr1sigtrnr (V^: <br />l sse to comply wirh sllCiryed County:-:::;af <br />COMMENTS <br />Site-Work <br />l-cde.s Addr6: