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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DI'LCARATION <br />I h.r.h, rntnr undcr lcnall, {)t pcrjury rhal I am cxcmpr liom lhc Conrrucro6 L-ic.n* Law for rhc n,llowing rcar,n (sc..7oll 5 <br />Busnus aM Prof.ssn,n Codc): Atry Cny or C.lnry which r.q!n s r p.nnit ro sn{dd. alrd. inpmvc. dcrmlish or to]l[n any <br />slrudurc. rior lo irs issurD.c. als. rcqutcs rhc applicrnr ror su.h lf,rnir ro ulc a signcd stalenrtrr lnal tuorshc h licco\cd puruanl <br />b lhe povhions.flhe Cotrl.arrof\ Li.!i$d ljw (Chtrrrer 9, Comncncins $irh Seclion 701)0 of Division I oi rhc Busifcs\ ud <br />Prnassiun\ Codc)orth,t hcorsh. ircrcnyl rhcrcfr,mmd Ihc h is for rh. rllce.dcrc'nprion Anyviol ionofSccrionT0Sl.5hyrny <br />ryrlica lorapcrni subjNis lhc applicnnr ro acivilpcnnhyoftror.rorclh..6rc hundrcd dolles ($5uJ). <br />l.asoancrofihcproFnr.orrlycnDkry.clwirh*!gcsusrhcirslccon,!.isation.willriorhdworkrMrtu{n.tonnnor <br />i cnd.d or oltarcd lar snlc (Se l0l,r. Rusircs Md Eofcsi,* C.dd'l h. C.nr'dclor's Liccnr ti} d.cs trol.pplyh $oqncr.i <br />rhc pmllcny who huilds or inlpmlcs rhcrcr and who docs ruch solt iinsclf or hcrcl, or rhrorgh hh or hcr o*n cmnn,y.cs. <br />pmlnhdrhirslch imnmrcmnrrrrcrer i.rcndcd oroll,:rcrl lorsrlc lt howcEr rh. lrildir8 orirnprolcBnr is{nd wirhlnoncJtr <br />oiconrllclion. rhc owncr auitlcr $illhor lhc nurdctr oftmrinE tht hc or dr did nol huild or improvc rhc nDrny fo. rh. pu'IxJe ol <br />]IOBBE&S]!!)!![ENSI|IION <br />l,rEcta&tMN <br />I hcrchy!fl nnrundcr 0cnrhyolpcrjuryoncolrhcfollowinEdalarrrions <br />-l <br />hdvc rM will nrinra r Ccrlificalc oicon*nl lo sclil,Nurc lor workc6-compctrsrlion. as Drovidcd iorbySErion.lTc,Oorrhc <br />tibor Cdlc. for rhc pcrf.rmnc. of lhc work for whkh rhc ,emil h issuM. <br />.rdwillnni rirworkcr'conracnsarioniNurdEc.isrcqurcdbyS$liotr:l7lDofrhcljhorCodc.li,rrhcruornrccof <br />nnwhich lhn!.mir h isnicn Myworkcrs uanc..rricr il I]oli.y numh.r !rc: <br />-lccrril!thrl <br />iD lhc |x hrinrn.c of <br />$ r\h hcc.nr \uhjccr roihe*orkcn <br />rvhich rht l]crnrir s i\$cd. I shill nor.n]nloy rfy per$n i'r rnI <br />'mnnLrtr h{r olCrlilortrir. rn{l rgrcc rhrr ifl \h.utlbc.onrc srbjc. o rhc <br />workrn co'rycrsxri,r tnvi\i.n\ of Socri{m .17fi) .f lhc LIxn (inh. l \lrril lnn h*i(h ( tr fly s ilh rho$ p(r i\i(trN <br />WARNING Frilurc ro scrc workcrs coNEnsdiotr ic nfln\nil. r nrll qrhlcd rn cn,llqrr ri, cnn,inrl |{nrlric\ rnd <br />cilil fincs ur lo orc hundrcd rhousind dollar (ii Mdiriotr ro rhc co\r .l con,tcnsdiotr. dxtrrgcs r\ ,,(,ridcd lnr rhc <br />scclim.loTa olrlE Lrlrn Codc- inlcr$rand <br />I )zt )te <br />-7 <br />DDCLIf,AIION <br />I hercbyamrmunderpcnaltyofpcrjurylhor I !n liccntodunderpmvnionolCho s 9 (conmencinB wilh Section 7mo) ot Divhion :l <br />of thc Busnrs dnd Prolcssions Codc. rd my liccns is i1 full forL! ard .irer. <br />a .,....---...\ <br />CONIIBUEIIQNIENIINIj-ACENIT <br />I hcrch, rffirn undcr pcnrlry.tperju'yrhrr rhcrc is r..n{rucrbn lending lgci.y f(r rhc pcrbn,r..c orrho work lbr which lhis acanil k <br />ns'cd (Scc 3097. Civ C ). <br />AITLICANLDECI"AIAIIA! <br />I hschy afmn undcr pctrolly ofperjury onc ol lhc l'ollowinS d(laraliotrs: <br />Dcnslirioh Pc trirs Asb.sos Noriicarion Ftdcnl R.BU l, iohr (Tirlc 40. Pan6) <br />R.quncd k(.r of Norifrariotr <br />I.cnitirlr rhc rcdcr.lr.!ul iotrsEgadir8 Nh.$.sr.Mvrlar. mt,fllrtrblcro rhis prelccl <br />-l <br />c.niiylh.l I hrvc rctrd rhh icalionnnd srarc rharlhcrtt)vc irrlnrnntiotr ncorcd laBrc ocomplyiirhdllCiry.idc.unry <br />ordinanccs rrd Slilc l-rws rchlifB huildir8 conslruclion..M hcrcby.ulhorh rcprescnrolivcs oflhis Cny ud Counry t, cnr6 rlbnrhc <br />ahovc rrc lidicd tbpcny fd <br />,\pplic{trtor AE€tri Sillnilur€"",",:Ze7//q <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />S igns (monument) <br />Li fe Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bonding / Groundinq / UFER <br />Translormers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Rool Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soflit Rouoh <br />Ceilings (T-Bar Rouqh) <br />Meter Belease <br />/) <br />Rouqh l0'1- It/hwld^ <br />Service lrileter v).... <br />FINAL 10"26-1{X.WJL <br />Notes, Remarks EtC. <br />-1. <br />as owmr ol rhc lmpcay. am cxclusilel, contraclirS pith liensd conlraclos lo onsltucr rlt pmj.rr (Sec 704.1, Bu\in s <br />md Euio.{)n C.de: Th. Contacktr'* Li.rnse Lls d@r nd amly ro an.w&r ofpropcdywho builds or improves lhcrmn, <br />and who conlmck lor sucn l,miBts wirh o Contmlo(9 liccnrd pursuanr to Ihc ConrlNrols Licensc Law) <br />lanex.mpr undcrSerioo_. B. & P.C. rbrrhissson <br />..-._-}\---...- <br />LctrJ"''. \ddr * <br />I <br />I <br />= <br />t-