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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hseby altm und6 p6aly ol Fjury lhar I m cx€npr Lom rhc ConkacroB Liccns. liw for rh. lollowins r@,n (S€? 701 L5 <br />Buvn6s md Poasion cod.): Ary Cny or Colnly which r.qun6 a Fnil to congod, ahd, inprorc ddolist or Epar sy <br />sltucr@, rior l. its isumcc. ats r.9un6 lh. rpplicst for su.h Fmn to fiL a siSnot sr.ldd rh.t hc or sh. n Ic6E ! pNel <br />to lhc lrovisioN oarh. Conlricloas Lian*d law (Chap|d I, Commflcins *,ith Sctioo 7000 of Divisio, I oi $. ausin* od <br />PDf€sioas Cod.) or lhot hc or shc is €rmp lhd.frcm dd rhc lBis for rh. rll.!.d .rdnplion. Any liolation of Sdion 701 L5 by any <br />aml,.dnl li" . lcmn subjccls lhc lpplicdl lo a.ivilp.nahyotnol morclhe fivc hundr€d dollm ($500) <br />-1. <br />a ownd oilhc proFny. or my €,nploy6 with wa86 c th.n sL comp€nsarion. wiu do lhe \ort aid lhc sl.rtr@ is nor <br />inlad.d o. olId.d aor sl. ( se.?o44, Busins dd Piofsions cod., Thr Conl.aclor's l.icGc l,aw do6 not apply lo e osn6 of <br />rhcp$pdy *ho hrildr oi ihpo!6 thd6lj. dd sho do6 skh Mrk himsclf or hNlf or thmu8h his or h.r owr cmployc. <br />providcd ln.t such imp.ovmls & nol inldd.d or oit6.d aor ek. If. ho{dd. the bu dnB or inprortml is eld Nhhi. o.. )e <br />olco,npldior! lh. O*nd Buildc *ill hlr $e hd&n of Fovin8 thal h€ or sh. did nol build o! inprovc thc pmpoly for lh€ pur!.F of <br />l. No$ncrofrh. propdy. M crclci!.1, conradine wnh li.ds.d.onr0.ro6ro conslrucr rh. Foj.cl (Sd.7014, Bc'ns <br />and ft.Gsio! Cod€ Th€ cd.kacloat l,iccnr Law do6 nol apply lo an osnd o t prop.ny who builds or imprors lh6sr, <br />md {ho .ontads for su.h Fojccl3 wjrh a Conuaclo(s) licsed puBldr ro rhcContacrori Licsc t rv). <br />-l <br />m cicmpr und6 S.clion-. B. & P.C. tor lhis rcen <br />Drte onn.r: <br />1!ll!t[Etss:g)!!fErf!-I]()! <br />DEEt^AIllA! <br />I hc'l1)! r|ntr, uml.r p.mlrr olpqjr) onc ofl[e f(r lo\ir! Jc.lrartlr: <br />_l hav. aod will naiotah a Csrificar. of Congr to S.lf-lNurc lor *ork.(' conlpcaslrion, a providcd lor by S<rion 1700 o lrhc <br />Libor Cdc lor lhc p6fommc. o I lhc wo* for shich lh. !€nrn i! issu.d. <br />I ha!. and will nainrain workerr onp.6.ri@ iEuGncc. 6 rcquiEd by Sd 6n 1700 o f rhc Labo. C.dc for thc polomdft ol <br />lh. sorl for $hich this pmir i! i$ql. My workdr .orpd&rion i6uec. ceid and polict .umbd d.: <br />PolicyNumba: Erpi6 <br />-l <br />ceniry lhal in lhc pstomanc€ of th€wo for s hich this p.mit is tsuel, I shall nol o.ploy any D€rson in any Duod$ e ro b..omc subjd lo rh. *ort6' coop.Mlion la\s orcalaomid. and dsra lhal il I should b..oto. subjdr ro rh. <br />worl6' .o,np.nsrion povisions ofsetion 1700 of th. Labor Code. I slEll, fonhLvirh conply wirh thos prcvisiotu.. <br />WARNINC Irailrrc to surc worl.B' compcalion corm!. is unbqtul. and sh.ll subjal an oplord <br />'o <br />oininal pqEli6 od <br />\nil fin.r ur ro on. hurdi.d rhnNrd '.lo'laB (tlLS.rc(l).addnion lo lhc c.$ of conpcMtion, damas6 s provided lo! thc <br />Code, ifleBt &d ftorncy s fG ./<-- <br />or!.l &tl&! <br />I neby arfi,n uodcr p.Mlty oi r,6jury lhal I m li6s.d undcr D.orision of Chaptd '] (.ommocins with S€lion ?000) ot Divisioo :1 <br />ol th€ Busins d ProfNiom Code od my lic.N isin lulllo(.ed.r<r. <br />ci3 4oxJ <br />I h@by ailm undd pcnrly olpdjury $al tn@ i! a .o$ttucrbn h.dii8 agdcy fo! rh. Ffolr11ee oafic erl lor stlich thi! rEmt b <br />bsu.d (s6. 309?, civ c.). <br />IlBrryrharrhe fcdo al , esul,rDns rcsddhs 6b6rosremo!alecnor opplic.blc!o rhBpmtd. <br />Pz-l cdrry rhd I ha!. @d rhis appli.arFn .nd {ar. r hd <br />'hc <br />,borc inaon.arion i! codd I agE ro .o,nply wiih ,ll Cily and Counry <br />o.din0rcB d Slste t4ws rcblinS ro buildin8 coBrrucrion. sd h6.by aulhoriz. r.Fe.larilc oarni! cn, d Counly lo dr6 upo. lhe <br />.bovc mmrion.d piopdy aor <br />CAppli.{nl or Agc lSiSnrlure <br />l'€mile nsn!e(prn'l):(-)oJ <br />,,f sf d <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />S pas, Pool, Fountains fI ilrl19 /L u4l j) <br />Signs (monupent) <br />Pool ue* sq l lzl(c /'^4lOr) <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 />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls Rou sh) <br />Ceilings (Hard & Soffit Rouoh <br />Ceilings (T-Bar Rough) <br />Meter Release <br />Rough <br />FINAL flu4 t1 Ltd4Q|) <br />Notes Remarks , EtC <br />Service lvleter t /tr <br />I endfl ! Addr6 <br />- <br />AIII.ISANLDICI.AMIIAN <br />I @afrm undd pqahy olpdjury on€ ol$. tollowing delealioNl <br />Dmolition Pmils-kbGtos Nolificalion F.d(al R.gu hrioN (Till. 40. Pan6) <br />-R.q0i.d <br />Lald of Notifi .dion <br />I <br />= <br />I