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ELECTRICAL-INSPECTOR RECOHD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDER DELCARATTON
<br />I hcrcby nffirm undcr pcnalr, of I'crjlry rhur I d cxchfl tu,n rhd c.ntd.tom Lkcnt ti* fo, rh. r{'lldwing r.a$n 1scc.70l l .5
<br />Bu\inc$ aia Ptulcasion a)d.): Any ciiy or C.unly *hich rcquncs o pcrnril b conrltucr. nlrf, inlpk'vc, dcmlhh or rcn,t rn,
<br />flcrurc, prir lo irs isudmc. nko rcquircs lhc ryplicunr lor slch ricrnnr b fi|.0 n8trcd slorcmnt thlllEorshc n licct\.d.0ursu.nr
<br />ro rhc Dnvthos ol rhc C.nt,.ror's Licctrs.d bw (Ch,pt.r ,, Conrmcrcins wirh Secrion 7m0 or Divhion J olthc Businu$ rtrd
<br />Prnfcrqions Cod.) .r rhar h.oishc is cxcmp[hcrcfrom Md rhc hosn for rhc lllcscdernr nrn. AnyviolariotrofscclionTn]l 5 hi rny
<br />spflicunr lor a !.rmn subjcclsrbc lppliclnrroacivilrEnrhrorn rmn rh,n fivc hundr.n dollltrs ($500)
<br />1 .3 owrrr .r rtu pn,pcrty. or nry cmploy.cs *irh wlscr !s I hcir $h dmp.ns.rion, sill do rhc wort $d itE ntum is n.r
<br />irtctrdcn o.oltcrcd for sL lSLi 7(144. Busi[c$ rtrd Pmfcssions colc: Thc Conrracroir l-kcny tiw docs nor ordy ro atr o$ncr of
<br />rhcl)n,ttny *tuJ hdilds .r irrprorcs rrrmn. and who dm\ skh tr. hnnt.lforhcscll'o'rhmulhhisorlEr.wncmPloyccs.
<br />provid.d rhlr such impmwn. s d mr irlcndcd or oAtEd nn strlc. ll ho{cver, rh. huildirg or iqmKntnl h sl] lirhin ono y.d
<br />of.onlFhrnnr, ihc olncr Buikr willtnrc rhc l,lrdcn ol pmvins lhal hc or \hc did mt boild or iilrrort lhc PmPcny fd rhc puqss of
<br />I.asosnci.rrhctmFdy..nrcxclusivclyconlraclinr*ilhli.cnsedconka.n)^b.on\lrucrrhcpNjccl(Sc.71lr4,Bu\iR$
<br />rnd Etrl6si,n Gdc: Thc Cont&roi s l-ic.ns. Lrwdocs noi $f lykJ rtros.cr ol pn,pcnlwh(' hdildr or nnfrovcs rhcrc.r
<br />rnd who .onrhcrs rDr ru.h Imjcds qnh . conln ro(s) liccR.d pur\uinr h rhc com.t,\ Licctr* uwr.
<br />latrr cxc ,Il undcr Sccr
<br />TABII8IITOUIENIAIII}N
<br />IIECI.ATAUAN
<br />I hcrchyrlTn uiirr Fnrkyorrrury.nc olrhc ftlhuin8 dccl.rarion\
<br />-l
<br />huve ud*illmainrrn, C.nitlcar. orCotrscnrto Scll-ltrsu,c lor "ukc^ ..nv.hsrn'n,.s tmvidc{lrorb,Sccrnn:1700ordc
<br />Ubor Codc. for rh. ncrtomme otrhc work ror *hich rh. n$nrir is issucd
<br />I hrvc andwillnriolrin workcN compcnsorion insumncc- as rcquircd hy Sc.rn,n 1700 of rhc &bor Codc, fo. rh. P(formrk! of
<br />rho *rk li1 trht'h rha p.mnr r\ trsum. M) worlcF' comtcniarii.n in.u' ..mrr Jftl Fl(y numbn rc
<br />c"",. ' )\<*\<- ?.-r...r..c\c\\21 \S +
<br />I ccdirrrhd in rhc lcrlarnmnccorlhc sort lor whichthh pcirnil G hsu.d.l \hru not.mrloy,ny p.non in anynunncr
<br />{o s lo l$om suhid lo rhc wo.tcn co,.pcn\ bi l,ws or crlironria. and nercdh4t ir! should h-con{ subjd t,lhc
<br />workcs'compcnsalionpiovhionsolScclionlT00otrhcl-trhnG)dc,lshnll.fof,hqithcomply*ilhrho{pDlitnr(
<br />WAnNIN(; rrilurc n) rcurc s.rkcrl .onrFtrsrri r o\ctulc is utrhtiul. r \lrll \ub]..r ai c llnoltr ro crinrinrl FBlrlc! rnd
<br />ciril finc\ u! b.nc hunddl rhousrtrd dollr\ (SlLx).UX)), ir !(ldilion h rhc (^r ol ronlBNrtiotr. dimgcs r\ pnrvnhd nr rhc
<br />sccrionlgT6 orrhc Llx, Gxr.. ir crcsrDl{6.\'.5 n Aao .,."- <r-lcl\S <r.d.(-1l
<br />DECI,AXAIION
<br />t hcFbr rm.mhdcr pcnrh, ol pcriury fiar l.n li$ns.d und.r .,oision ofCtaflcr 9 (omdtidg {irh sdio. ?000) olDivhion l
<br />of ltf, Busirc$ and Prcicsions Code. sxl my liccns h in tull ao,a aid elrdr.
<br />(l) \1t -\ c\.
<br />C!}IIBUIIIONIENIJING.trGEII]I
<br />I lrcrcl,y ann'nundcr Fn'lry.rr.riu.ythd rhr. is. snsrtudion kndinS rscrcy for rh. pdr.rmnL! urihc vort aot shich lhis Frmh n
<br />issucd rScc.3097- Civ. C.)
<br />^ItLl!]INLlJllI
<br />.BAuor
<br />I lu!$yrin uftl$ I)cfrlry.l perjurr onc ol rh.lnlk)sinI dccirrrrion\
<br />Dc nilirtrr,Ic'nrirs A\h.!.( N.ri,i.arlon IiJcrrl Rcauhiid,! ( lillc l1). Irn6)
<br />Rc(tuircd Lclrcr ol Norili{ri,n
<br />l.cdiryrhrr rhc fc,lcrulrcguhrii)is r.Ei',lifg rsl{{os 'c rvalfu. f.rrt,fli.rblc 6rl,i\ fflIr(
<br />ord frtrLrs rtrd Shlc trsrrcldin8 ion. ald hcrhy adhrik r.Fcscmllivc! oflhh Ciry and Counryro.nrd ur.nrlE
<br />rtn,vc nrorioncd pnrlfny
<br />Appti€nl or A[.nl SiAm
<br />K_\q$4
<br />'E'Q. iE
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Lite Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Buildinq
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Solf it Rouqh
<br />Ceilings (T-Bar Bouoh)
<br />[/eter Release
<br />Rouqh
<br />Service NIeter
<br />FINAL c " 2L-/9 J/rh-1,,cvr)
<br />Notes, Remarks, Etc
<br />Communicalions Cable
<br />Air Conditioners
<br />\-=--
<br />Irnd..! Addtrs\:
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