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ELECTBICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDEN D'LCARATION
<br />I hctuby affinn lndcr !.nrh, ol pcljury rhlr I !m cremFr frcm thc ConlradoN Liccnsc LIw Ior rhc followin8 rcasn (Scc.Tollrt
<br />Busincs tnd Porc\ii.n C.dc) 46, Ciry o, Colnl, which rcquircs a lermir lo con(rucr. rlrs. imtrovc- d€mlish or rcpair any
<br />slndurc. pri.rlo irs isqunnc.. alo rcqutci thc lpplicad ftnsuch pern r b llh r sistud sr ctunr rhut h!or shc is li.cnscd p!^!mr
<br />ro rhc fovhions ol
<br />'he
<br />Conlncfttri l-iccn{d tjw lchlprcr 9. Comnctrcnrs with sedio. 70oo ol oivkin I of thc Busircs ind
<br />Pmic$ions Codc) or rhr' h. or shc is cxcnlpr rh.ermn aod rh. tissh r{tr rhc !lrcsed cicmprion AnyvnnlrionotSccrionT0.ll5byan,
<br />rmlicanr for a pclnrir subjccrsrhc lprliconr lo acivilI)cnrl'yol.or nx,crh.n livc hundrcddollds ($5m).
<br />-1.
<br />as owncr ol thc ,),orcny. or ry cnDloyces wnh woe( rs rhcn $b dnnp.n{rion, will do lh. work and d. (tulm n rct
<br />inrmd.d or oficrcd ror *tc lse.- 7044. Busincss and Proacs\ions Codc: Thc Conrroclois Liccnsc tiq &cs nol alply ro .n o*rr ot
<br />lhc pmpcrly who builds or improv$ rhcMn..rd Nho dms such wo* him*lfor h.rsclr.r rhonsh hh r h.r 6wn cmrr,y..s.
<br />providcd rhar such impnrcmnls arc nol inbncd or ofcr.rl for slc. Il howcw. rh. boilding or ir!trokftni is $ld *iih'n onc F{of.oq,ldion- tnc Owns Buildd willha\r ur buidcn of pdling rhrr tE or snc dil er hqild or in{reE rhc lotcny aor rh. puqnc ol
<br />l. 3s os'rcr of
<br />'hc
<br />pn,Fnr. anr ckllsivcly co raclinS wnh ftc.scn co rac'or to.onstrud rhc poid(S(.71!4. !u!ine$
<br />a.d PrtriLxsi Codc:Th.Co.t0.ror'sLiccnscLdwd.cslorapplyro$osncroaprop.nywtohuildsori,nprorc.rh.r.on.
<br />,nd wkl onrrocrs f{r \!ch rroick sirh a ConrEdo(s) li.cnscd Dutrua rorhcCo ra.rors Li.cnc tjw)
<br />I ao .x.rpr ldcr Sstion_. B. & P.C lor rhis rsen
<br />D.rr: ()*n.r:
<br />WoRTFRS' CoMPENSAT(TN
<br />I'LELAIAIIAN
<br />I h..ch,lfitmundcrl].nrll,orpcrjuryoncofth.follo*ingd..lr bns:
<br />_l havc aM will truirhin a Cc iar0t. ul Clotrscnr b Sclt ln\urc arr $ukcrf conpchurirnr, as povidcd i(n $y Sdln'n .l7{D of rlf,
<br />Lnhor C'odc. for th. ,)cdnrmn.c of rhc w.& ftr whih ih. pc.mil i\ issucd
<br />I hnle and willnointain *orkcF conFnurbn insurlncc. as rcquncd byScdion3?0Oollhc Labor Odc. io,lh. pc ornumcof
<br />rlr wnrk ntr!hi(h rhis pc rnrir h nsLn Myworkss conrtcnsarion imurmcc.amier ard lDlicy numbcr dc
<br />rl 'l \Arr.t\t Cd gl". a.Y.6,
<br />J
<br />-l
<br />ccniry rh,r i. rh. p.rronuftc.r rhc sork tur which rti\ pcrmit n isucd. I sh,ll nor emplo)' any pcron in lny oann*$ N b bccom subjNt Io Ihc workcF compctrsation lnws olc,liroiri\ d nSrr ih.l ifl skJuld hc.otr suhjcd lolhc
<br />work.( conpcns,rionpmvisions orSccrnrn l70O.lllrc bhor cod..l sh.ll. ri'nnwilh con,ly wirh rh.c EovGt'ns.
<br />WARNNC: Failurc ro *curc workcs co rtrNarion ..!rngc ir rnl,saul, ,nd (hall suhj..r ,r cnllldycr Io dirinol lEmlrics Md
<br />cilil fincs up r. onc hundr.d rhousrtrd dolldrs ($1fi).m0). in addirion ro rhc con or$ny.n\arion. d, D!.! .s fovidcd hr rhc
<br />Sarbn 1076of$c tibor Gxlc, inrcr.sr and,tortuy s re1
<br />frAY 17 2010
<br />IhcEbyrfiilmu.derpcmltyofDcrjurylh0tl.mliNns{undcipmvhkrnoaChrtrcr9(.onrmni.8RilhSc.rirn7tD0)ofDivision3
<br />of lic Busincs rnd Profcssir.s Codc. dd myli.cn$c ir i'r fullfo@ddcffccr
<br />loo
<br />c""r,,"r". V-a,,!r"L?rzt-*'l'f,A]-lT7dir
<br />(r)NsIkt(t t()N t t:Nt)tN(; \(;tiN( \'
<br />I hceby uffirmundcr pcmlryoalcrjury rh lh€rc k a onnruclion hndrng r[ercy hr rh. tslormncc ol lhc work lor *hich rhh lcmil k
<br />nslcd (Scc. 109?. Civ C.l
<br />6.EILICANI.IDCI,IEAIION
<br />I tmbt .fm undr p..alry of p.r.iury om of ttu follosing dc.ladr i.ns:
<br />D.trhlIi.n P.imi*-Asb.(os Norirlcrrion FcdeBl Re3!lations (Titlc 40, P{da,
<br />-Rcqun
<br />d kn$of Notiarcario.
<br />-lccnilylhal
<br />thc lcdcr0l rcCllolioos rcSudin8 asnc$os rcmovslrr. not aptlicablc to lhh Imic'
<br />l.cnili rhnr I hrvc r.rn ihi\qJf lMritnrxjirr. rl dh rll,v. tr,itrtrr.tritI n h.onrd, qirlr rll ciit rtul (itrtrry
<br />frhn Ciry Md Cotriry r, ctrrc! l]fui rlrordirntr.c! rtrd srrrc l-rw{ rclnr 1,l3 i, huildinScointurrir)n_ rnd hr
<br />nli,vr krirtrdLt)roII'rr r(n n\l).(rii]tr ptr
<br />ADplicantor,\*$l Si*nslum:
<br />Pemiree nhnrtprini): -9ag,t7 Ar
<br />Site-Work
<br />Undqrground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life S /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />Itileter Release
<br />Rough 5n /h z>r*t?.7\**g
<br />?/7-1/i$>r\ ta(
<br />Notes, Remarks, Etc.
<br />fC-t
<br />Service IVleter
<br />FINAL
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