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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCNRATION <br />I hcrehy !ffrm udcr Il.nah, of pcrhry rhar I d .xcryt from rhc Crnrrn r6G Lk.M b* ft, <br />'he <br />follo*ing r.asn (S(.?oll.5 <br />Busin.ss {ld Prcfersi.n Codc}: Any cnt or county which ftquiBs i Fnnir ro onidcl. !1t6. impmye. dcm'lirt or rcnsi uy <br />sructuc, prior ro ns issu!trcc, o rquncs lhc sppltant lor such Ilrni k' lilc a risncd sllrcftfl rhll & or ch. k li...(d Pummr <br />ro rh. povhbnr of rhc Conr.d.t r Liccns.d hw (ch+r.r 9. commn.ing wirh Scction ?filo of Divisiotr I of rhc Buiincss atd <br />Pmfcssions Codc) or lhll hc or shc is€rcnfl lncrcfnn otrd lh. host for rhc llks.d eieq)iion Anyriohrirmorsc.rionTosl5 by {ny <br />dpplicanr ror a pcmn soblcck th. amlicam ro acivilpriahyornor moroda. fivc hlndred dollcs ($500) <br />-1. <br />as oRrcr of ih. pmpcny. or flry cmployes wnh woBcs !s lhcir olc conq'cnsal ion- wiU do rhc work snd rh. imrurc i\ nor <br />i cndcn or olicrcd lhr sih (Se_.?044. Businc$ and Pmicssiotrs Cods Thc Conk!.lors l-kcnk Liw d.cs nor lnt'lylo nnowncr ol <br />rhcpstfny who buildr or irv,mvcs rh.ron. rrd Bho d6 seh m* hinsclf.r hcrsll or rhou8h hn or herown cnployccs, <br />pmvidcd rhar such imlhv.ftnh d fr, inr.ndcd or ofici.d nr eL. Il hoqcvcr, rtr ttriltmg or inDmEnEnr h bld sirhin om Fu <br />ol coq,ldion, ilE Owmr Buiklc, will huw rnc brdcn otprovins rh€! hc or \h. dil tr.r huih or inpmrc thc psFly lor lfu puqns ol <br />I..rownmofrh. !mp.n y. .h cxclus ivcl, contr.ling wnh li.cns.dcontricrorsroconntucl rlE pmj€l (Scc ?044.8u\ifts <br />ard hofsshnCodcr TncConlractors l-iccnr l,awdocs nolarplyro Mo*n.rorpmp. y *ho builds o. nnfmvcs thcr$n. <br />and sho comrers n, \u.h ,,nj.\h wirh Comacb(r) lkcn$d rusud n,rheConkcrols Liccnsc hw) <br />I rmcrrrpr undcr S..r() <br />W()RXERS' (ll)MPI,-NSA f ION <br />DECI"AMI]AN <br />I hcrchyrftn ruiddrFcnnlryolFrluryon.oflhclollowingd..lardtiotrs <br />I h!v. ard will minrain d Ccniltrdrc ol Conscnr to Sclf lnsur. lor worlcn conf.nsdion. 3\ Imvidql lor by Serion ]7u) of rhe <br />tjlxn c{dc, fu rh. pcrfoM.. of rh. *urk id whi.h rh. Jxmn i< isrusl <br />-l <br />holc .nd uill <br />'Minlrin <br />workcs cotrllEnsarhn insuEmc. as rcquircd l,y Sc.rion l7m ot rh. tihor C-odc. tu rh. ,nforrorcc of <br />lhc work for whth lhk,Ennil is hsEn. My workcrs €omp.nelion itrsunmc cartr and Flty nuftb.r @: <br />"^-*,, 9*1e {und <br />qzl l3s'i l 1 5 zk lx, <br />Iccdifyrhar in rh. pcifonnr c.frhcvorkfuwhichrhi.$nnir ir issucd. I sh.ll nor cmtrloy any pcAon inant'nrnncr <br />so !s ro bccom suhjccr lo rhc wolkcn'comrcns ion hws ol'Clliixnia. and astuc rhar irl sh.uld h.&nrsbicct rorhc <br />wortcn' conrlrcnsution Inovhions ol Scdion :1700 oi rhc Ltrhor Codc. I \hnll- r,,nh$irh .onFly wirh rho{ I)n,visios <br />'A'l',i 1|nc36 <br />S.zY it <br />cotrslf,lJcnolttENDaclc[lcr <br />I lf,rcby!,firm urdcr rEmlryofF jDryrh!1 rhcrc isa cond crion !.ndi.8 a8.my for lhc p.rformrc ofuhc *ork for {hich thii lFdn ir <br />hsued isc. 3097. Civ. C.). <br />ATIIICANfDECI.AAAU!}N <br />I lErd,yanimrundcr pcnalty ofpcrjur, orc of rhc tollo*in8 dcclmriors: <br />Dcnblilion Pcrmils-Asbcsros Noiiricllion Fcdcnl Rqulolions ('rilE 1.0. Pnn6) <br />-Rcquircd <br />t rtcr of Norif{.lk n <br />-l <br />cslily thar rlE fcdcnl rcsllr' ioos Esrdi.e f,rLdor rcn'ral,i. Nn,rpli.ahlc lo rnis pojccl. <br />EU ftdiry rhd t tuw rcad rhk trppltarbn,nd sr,icrh.r $c ahovc inroi,urio. is coftn I a!@ ro ohpty wirh dllcirrrnd counry <br />reprcsenrarives ofrhk Ciry and C.unryto cnrn urdn fic <br />,,," s'2J {8 <br />la <br />xtxn. nrnrnrncd ptr)pcn! lnr instr(r <br />u"-n*.".",rn*,, Kfn b< rl-1 l,t nzu4 <br />Site-Work <br />Underground <br />Light Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bondinq i Groundinq / UFER <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Bouqh <br />Ceilings (T-Bar Rough) <br />It/eter Release <br />Rough HzzlrC -Aa-qfi q) <br />tl <br />FINAL lt /{,b lg 5b€rX <br />Notes, Remarks, Etc <br />Pole Bases <br />Service Meter <br />WARNINC: F.ilur. ro suc workds mmpcnelion .o!.Bgc is unlowtul. otrd shrll subj.{l an cq,lo,tr ro dninal IEMhi.s tnd <br />chil fines xp ro o.. huMi.d rhous.d doll6 (Slm.ooo). in lddnioo lo rnc cosr olcomp€osario.. ds@gcr 3 rovid.d lor rh. <br />Serion 1016 ofrhc bbor Codc. inhrcn ad arromy s lccs <br />,,,., 5 zYrls n,n^,.# V&4&-- <br />LIcEMED-lllNIldrroi <br />DECI,AXd]IQ! <br />I hcEbyomnnuodcr prnllryofncrjuryrhdl I rln lien!.d undf Fovkion ofCh.ptcr 9 (ammncin8 with Sdion 70()()) ot Divi*ioo.) <br />of lhe Busirc$and Pmlbssions Codc. anl myliccn* n in nrll forc and cfter <br />L.ndcis Addrc$ <br />- <br />Applicsnt or AI.nl SiEnnlurc: <br />II <br />f -----T------