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ELECTRICAL-INSPECTOR RECOHD <br />APPROVALS ID/SIG.COMMENTS OWNER BUII,DER DELCARATION <br />I hcrcby afilrm undcr Plndlry of rcrjury Ihal I m dcnfl rmnr $c Conr.lcro6 Liusc tis fot rhc ruuowins rclsn (Sm 7(R l 5 <br />Blsirc$ snd Porc$io. C.dc): An, Cnt or counry which rcquncc t Pcmil ro onsr cr. ulr.r. nnprou. d'@lish or EPair 8nv <br />srru.iuE.Iriorlo ns isumq,ko rcquircs rh.,ptli.a.r ror sx.h Fn,n lo fikrariSn d slllcNnl rh{r h.o. shc is liccn{d nursutnt / <br />b rh. rovisions oflhc ConrBcror's Li.cnrcd t w lchaplcr 9, Conmcnciirs silh Scction ?m0 of Divnion I of$' BusnEs 'ndP r.sions Codc) or rhsl h. ot shc is cxcm lh.rciion&d rlE tEsis tu thc alLscd.rcoll,tiotr Anv vnnarnrn of Selhn 703 L bv 'nv <br />aptlicnbr lor a pcmir {uhjds rhc amlicanr lo a civil pcnaxy ol not mrc lhan nvc hundred dollm (S50o). <br />-1, <br />as owncr otrh. pmpcny. or 6y cnplo)Ns virn w,8cs.s rhct v,L coryrnsolion. silldo rtr wdk ald thc {Mm k mr <br />inrcndrd or off.rcd for $lc I S( 7044. Businc$ ond hltc$iotrs Codc l hc Conlru.has Licc.sc t wdocinorlpIlvl.0nowncror <br />rhc llDpc.ry rho builds oi iqroK rhcrsn. tr*r who de\ cEh wrt hinr\clfor hcrtlfor rhmu8h his or icr own cBpkirtcs- <br />,,iovidcd rhal suct impmwrEnt e ml inrend.n or oflcrst n, {b. l( ho*c\s rhc tuilding or inptu(mnr is $ld *nhin oro vu <br />.r.omDhriotr. rh. Owncr BuiHs will haE thc burdcD ol povin8 rhd tE or shc dil nor bui or in[mvc lh. Po|fnv for thc I,!IIF{ or <br />l. N owncr ot rhc llr,rtny. an cxclusircly conrrrrirrg wirh licctr*dconrtrro b.o.soct rhc P(rjccr (scc 7O+r' B 'i"" <br />lnd Ptr'f6sbn Culc ThcConrEcrois I-i..nsc tjsd@s norrnllyh nnowmr oflrcpcnywho buildsor iml]ovc\ rhcrcon. <br />rnd who $ntmcts r'or sn.h pmjNrs wilh a Conrrucrorlsr lkcnscd luNutrtr rorhccontodois l-ien\c b*). <br />I nncxcDrtn tndcr Sccrn <br />-, <br />B &PC lorihi\r.rvrr <br />Dat. Oer6: <br />WORKERI' C()IIii'FNSATI(}N <br />DECIITEAIIO! <br />I hcrchy afl irm uid.r p.nrltrof lsjuryom orrh. rollowirB dalomrioas: <br />-lhureand*illneinriinrCcni,icolcofCon$niroScl <br />nsurcforworkcn.onDcnsrlio.-N pmvirlc{ lor hvs'crid:17(x) 'l'rhctih.r Oodc. fnr rhc pcrfomn.. ol lic wotk for whth rhc p.rnrir is issutd <br />-lhuvcand*illmin <br />ainworkcr co'npcn\0lion insuruncc. as reqnncd bv Sccrion:l?O{)ofrhc Lahor Code fitr lhc frri}rnuncc of <br />lhc $ort fo. whi.hrhnpcmir is isskd MyworkcG .omlEnslion i.\unrcccatrt, ind B,lky trunbcr Ec <br />Policy Nu6b.r <br />-Er!i6s: <br />-l.cniryrhrrinlhcl]crronnaN.olrhcworkfor$hichrhilr.rn i{ hsucd l \hrll Dor cmllov nnv pt^.n nr rnv mlnn'r <br />$ s k, hcco'ru ub].d r. rhc worlc6 conFnurion ldws ol Cnlifomi!. and isN lhd iII sbnld <br />*ork.s omrcnsari,,n Froviiions olSatjon l?fii ofrh. tjtbr Codc.l rhall ron hsir h omPlv {iih rk <br />WARNING lrdilurc b {.urc w.rk rl conrt^-n\dio. cov.rng. i! utrliltl. ud nhll <br />civil nncs up ro onc hunnlcd rhourand dollar (!l(X),fi)or. in rddirio.lo rhc con <br />Sc.ri,r' 1016olrh.lrlxtr O r. irrr.rc{ rnn r(ornc} \ fc.\ <br />o*., S-/ 6- -/g a,pn-, <br />I hcEbyllfiflnundcr P.nalryolPctiury rhd I um [ensd undcr Pr.ehion oiCh,plcr 9 (codmfti.8 wilh Sr.-rirn 70u) otDivhio' ] <br />ol rhe Businc$ and PDressions Codc. ad nyliccn* is ir tull lorcc lrl.ffL{r <br />e <br />s--/6- <br />I hcruby rfinn undcr ltnllry.tFrjurt rh.r rhere h r consltucrbn Lndin.! r8ck-^y lor rhd pcrt.rnrncc orrh. work tbr rhich rhn Fnnr is <br />Rnrcd (Scc.:1097. Civ C ) <br />APPLICAN Nf(II ARAl'ION <br />I llaEbyaninnrndcr prtrrhy oiteriur, onc.lrhc l.lkrwins dc.nvalioi\: <br />Dc rlirion Pcrmir! Asl,cnos Norificrrinn lcdcral R.srlarnnr\ (Tirlc 40. P3n6) <br />Rcquircd ldrcr or Norin.dion <br />rhnt rhclcdcrrlresuhrn N ^_Aa(lir8 ashcnos rcnn) <br />#.*lr yrhN llnr. rrxd rl,^ r|t)lrnri,rrnrl {rr.rhxr(lrcr roconrdyqilhall Cir, rtrd cotrtrry <br />olrht Ciry Md Counrylo cdr.r u,mn Ihc <br />atnrc trf, ri.'rd llo|].ny iot <br />Applicnnl or A!.nl si*trrlu s-te-1/ <br />Site-Work <br />Underground <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Founlains <br />Sions (monument) <br />Life Salety /Low Voltage <br />Fire Alarm i Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bondinq / Groundinq / UFER <br />Translormers <br />Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Rool Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soflit Rouoh <br />Ceilinos (T-Bar Rouoh) <br />Itrleter Release <br />Rouqh Sl,nltY €Ntblw W <br />Service I\Ieter <br />FINAL // ////f Zr/k71,L-z€-- <br />7 -/ t-Notes, Remarks, Etc <br />DATE <br />q <br />knJcr s Addrc$'-