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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE IDiSIG.COMMENTS OWNER BUILDER DELCARAIION
<br />I hcrcty aifirm utrdcr pcnalry ol rrjury lhol I a,n cxcmpl fDar lhc Conl.rrnn l,tense Laq ror rh. rollowidS rco$n (sL{.7or1.5
<br />Bu\inc$ snd Prot $ion C{dc): Any Ciry or Colnr, whih rcqltcs a lrmh ro .ui{ru.r. rkcr, impn,rc. dcnnnhh or rcNn ony
<br />ifl.rrc, pri., r, ir\ issxftd, also mquirs rh. ,ppli.anr t r rn h Farnl io hL { siSncd {abnrnl rhlt lE or shc n liccNcd pu6uinl
<br />to rhc poviiions of lhc Contrrror's Liccn*d trw tcn0ptcr 9, Co rmercin-q wirh Scctn,n 7(Xx) o, Divnion I ofrhc Busincsl,trd
<br />horc$ions Codc) or ltiltE or \hc is cxcmpl lhcaft,nrsftl lhc tEsis n rhclllcs.Jcr.nflnnr.Anyvn,hriotrofSerionT0:ll5hrrny
<br />rtplicr r turrp.nnn suhjc.trhc aprlicrtrrro,.ivilp.nrhyofmr x,orha. firc hundrcd dollas ($soo)
<br />_1. ds own.r oa rhe pFIEny. or ny cmploy.es wirh sdScs ns rhet slc co.9.ns.rn,n. will do dr w.d ail rts dutw i\ nol
<br />idcndcd or ofcrcd for nnc (Ss ?044. Busircss otrd Pmr.s\ions Codc: Thc Controcrols l-tcnsc L!* dms noi ardyro rnownd or
<br />rhc pnFn, $h)tloildroritr olB rltBr. ad *lD des sEh err hinFclf.r h&sclr or rhough his o. hc. own cmployccs.
<br />nrovidLrd rhtrt such irllrov.nf,nB dc trol inrcnLd or oficrud for $lc. Il howcwr, rh. hoilding or im0mvcrrcnl is sld wirhin onc )eu
<br />.f..'elcrbn, rlrOwn.r Bniu.r eillhtrE rlr t idchdfpovingrhdtrorshjdidk boild or iqmrc rh. pmtmy ro lhc l]lqne ol
<br />I. ,{ owmr or rhd J,orcny, dmcx.lxsiv.lycotrrh.rin8 si'h li..n$d .ont,croN lo .anerud thc nn+.r (Ss. ?044. Bu\incs
<br />ond hnis\i Codc:'fhcConlrucrolsLiccnscL{*de\notnpnlyl,)aoo{nqnfpmnnywho$!il.horiniprovcsihcr.on.
<br />rnd who onrds for such pmJc€k pnh r ConrNh(t li.cnseit Du6u!flr ro rrE Conrrlcrois Lic€n* Lw)
<br />I onrcxcnrtr undcr Scctio 3 &PC lbrlhisrciv,n
<br />uaBK[&tgqufENsaroN
<br />DI:CLAa -I!Ar
<br />I hcrchy rflnmrn.lcr r--nrlr, ol pcrjry otrc ofrhc l,nkNin! dcchmri(nN:
<br />-l
<br />hrvc iril willm nrri,r a crcrlificrrc ofCu.scnr ro s.lf.lnsurc f.r worketr snlpenBrion.6 pmvided in btsccrion:1700 ofrhj
<br />bktr Corlc.ltr Ihc J,sforntrtrc ollhc rclt lor whi.h ihc fsnlir t is$cd.
<br />rhc *ork fq*hichrhis p.rnrir i\ isu.d llly worl.( cotrlPcnqrnm in\lrrmccM'cr a*l tx'l{ynu rh.r uc
<br />Cartr:-
<br />, r.nifyrhd i', rhc r(na rn.colrlrworklar*hihrhi\nrnn[|nnnl.lshrlln.rcnrployanypcrorinanyunncr
<br />s nsro hcorr \rh]cd lo rhc $odcn conrpcns{rnrn h$\oiCrlifornir. rndl8rcc rtur it I \horld hc$m srhFrr k'irt
<br />so*ci\ conrr.nsarion0rovklonrorSccrion.lT(X)oflhcljt{r(odc.lshrll.Ionhwirhconrpl,sirhrho{px)virn \
<br />WARNINC Frinrc k) r'ctr,. so.kc.s .onlrnrx,iotr .ov.fu!.bj..r ,n cnrtloFr lo niminal Fmhics lnd
<br />.'!il lnr\ rp n' onc hu lrr rh.usrnd dollrr (Sllx).lxxJ). i'r dir:ffi:L
<br />DECLAAAIIOX
<br />I h.mh,"ni.u uhdcr p.nahy.lp.rjury lhd I am liens.d und.r pmvkio. olCh.rrs 9 (smmmins sith S6ihn 7(xn) orDivhbn:l
<br />or rhc Burincss Md Pbfcsions C.dc. aid my lkc.s. is io full foM ,nd .lficl.
<br />ZI
<br />IANSI&EIIONIENDIIiIA{jINI}
<br />issucd(Se.. 1097. Civ C ).
<br />rl-tfut rtl2ljcl B,!rI!t!
<br />I lx'r1)vrnnnu,lcrr rlrlorIf,'ttrr!.f.ol rher,,ll,)trrtr9rlc.lrdirfl\
<br />t)cntrniior I'crnrn\ A\h.{rs Norirllrri{r lt{lcrrl Rrgulxrnnx I tirI to. lrl,16)
<br />Itc!r r.d lriorol Nollicrr.tr
<br />I ..nlli rhni rhc 1!(hrn rcrnllri,itr\ rcErni',9 r\t\n,N rctrn,vrlr r tror rl)fli.rhl. n) rhA f',t!.r
<br />onlinnrcc\ 3nd Srarc hw\ rcldiog r. bu
<br />rh.\c,,rn,oncd rF,rny rnr in\fon
<br />a ppll,'rnt or AS.nl Sign.luft ]\
<br />rnd h.r.h\ , urhitr /r rctl'c\. xr \.\ ofrlri( (lrI
<br />o{K (&?V;t,^;
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Translormers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />[/eter Release
<br />,{
<br />Bough 6-24-lY vl&14\
<br />Service Meter /;=
<br />FINAL '1.ro,/ E I t/4 *.,rc,t .514'/)
<br />Notes Remarks, Etc
<br />l.nJr \ 'lJ'"r
<br />Site-Work
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