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ELECTRICAL.INSPECTOR BECORD
<br />APPROVALS DATE ID/SIG.OWNEB BUII,DER D'LCARATI(}N
<br />I h.rehy slrrn x.df ,.n,lry rf perjxry rh.t I m .xcnqr anrm rh. Conra.roN Litns bw io! thc followin8 rclr,n (Scc'.7011.5
<br />Busi.css d Prorcssi.n Codc) Any Citt or Counly Nhi.h r.qut s a pcnnil ro onslruct. !ltc( inprolc. dcnmlish .r rcn,n lnv
<br />strucrurc. prior ro ns nsunrcc. als rcqlics rh€ applica lor such lrmil 'o
<br />file a sisncd slatcmn! lhllhcorih.isli..nsdl)urtunr
<br />ro rhc tmvGioni orrtr Conkr.lor's Liccnscd rjw (ch,/.r 9. connroncnrS wi'h Sccriotr 7m0 of Division I of rhc Buiines and
<br />Pmfc$ions Codc) o! thrr lEorshc ncrcmpr rh€relmm.nd thc brst lorthcalkBcdgemprion Anyliolurionofs(rion70ll5hyd.,
<br />aptlicanr lor a p.mn sutjcclr rhe opplicrnlt,rcivilFnahyolnormGrhanfiv.hnnli€dd6ll$($50o).
<br />I. ns ownftorthc pftrFny. or myc,Iplo)$s wnh wNAcs a\ thct vnc.onEnsaln,n. $illdo lhc so u{thcntur@isnn
<br />inlcd.n or oncrcd for sl€ ( Sa ?044, ausioc$ and kofc$iotrs Codc Th. Conrrd.is I -ienr I rw dfti nor ,mly ro owmrol
<br />rh. Fmtrtry wh. builds or inpm\$ thNr. md who do.s Nch wo* hnDsclfot hcnclfor rhroqrr hn orterown cry,loyccs,
<br />prorid.d rhar such impmeEnkmhr inrcided ororLcd lor qk ll lt,q.!ri rh. bxikling .r nnld)ENnt is bH *ilh tr or( rr
<br />ol conq,Lrio.. th. o$'mr Buildn will har lhc burdcn ol F.vin8 rlla hc or shc dil ml build or impnrE lhe lorEdy for rh ruqb$ or
<br />-l..sow.erof
<br />rhc popcny. amcxclusivclyconhclin8 with li.cnscd conrmclns lo onsrd.r tlE pmJcct (Sdc ?ofi. Bu\inc$
<br />ind Pft,L$hn C.d.: Thc conra.ror's LiNnsc Lrs docs i.r rrplt r, !n owncr of |)(,lr ywho huildso! inrpmvcs rhcrc.n.
<br />lnd who conkack for such pmjNls wirh . Co.rrocro( n liccnsd pursulnr ro rne G,nr,dois Liccnsc bw)
<br />-l.n*cnol
<br />undc. Sccrn)
<br />IOBKEBIIjOMIENIA.IIQN
<br />DTIIA.B{TA!
<br />I hcrcby afllrr un'1.r,-rndryof!.iluryom ofrh. nrb*in8 dc.hrnrons
<br />-l
<br />hrvc 0nd vill nDinrain i Ccn ifrlrc of Cotrrc to Sclf-lnsrc lor wo.kcrr conrncnsalio.- rs protidcd tor by sdrion lr00 olrh.
<br />tih)r CdL. for rh. pdf.nMft. of rh. work for whkh rh. Frdir ir irsucd
<br />lhavcandwillnrinlainwo.kcrlcomFnsorionnrsuramc..srcquncdbyScclion3?mollheliborCode.forrhcFrrortun.cor
<br />ir ilsrd. Mtworkcs lrmtrnsarion iNur,fr..ori.r,d nolicynumbcr rc
<br />f2]!v vJ( ct3l rA o \.r- l q.v-
<br />-lccnilirhd
<br />ir thc pcrfo,nuncc ofrlr sork for which rhis fcrnrir n ksucd. I shull nol cmfk)y lny ncron in rny maii.r
<br />s, a\h hecotrr \uhjccr ro rhe {orkc6 .onrpci\orion l,ws of Crlif{mir- and rsre rhrr irl \k,tld bce,ft suhjc.l lo rhc
<br />*ortni.omp.n{rn,npn,vi\io.sofSccrnrnlT0OofrhcLrhtrCodc.lshrll.f(,nh*irh.ortlysirhrlxr*trovisi(,ns
<br />IIARNINC Failurc b ccurc wortcr conrpcnsition covcrisc is utrla$Iul. and shlll \uhjccr an cnpby.r t, d inrl Fnahics md
<br />civil fines uI to o.c hundrcd rh.usnd dollan (Sl{n.OOo), in.ddnion ro lhc co( orconpcn$rion. datut.\ !s rruvdcd ror rhc
<br />Scclion 1016ofrhc Latn 6dc. ir crc(a allorncy\ ltcs
<br />,,,,",HAY l? lofi IJIJ,IIIITS]NIBA1.IA,B
<br />DECIASAIIIIN
<br />I hcchy !fiirm undcr pcmlry of perj!ry lhar I !n lien$d !.dcr p{.!nion.tChafl€r 9 (.orftfting wnh sNrio. ?0Oo) oiDivhn n l
<br />ol thc Busircs and Pmlcssions Codc, and my liccnsc is nr full lbr$ md cl{cl
<br />€,^loona$qtrr-uru (on,h,,or Y-a'+<x,t>.
<br />SONSIIII:II()NI.EIDAG.ACEI{CI
<br />I heEby aifinn under Fnrltyolpcrjuryrhar rhcre h acon(rucrion lcndinBrscncy [r rhc lcrronfln.c.rlhc work lbr whic[ thn pcrnril t
<br />nsucd (scc. 1097. Civ C ).
<br />AITLIC'XIDICI,ABAIII.IN
<br />I hmby niifr undcr !.n.lty of pcrju.y orc or lhc followin8 dele{l n,ns
<br />Dcnbliri.. Pcrnirs Alb*ros Norincdion Fcdcrrl R.gulariotrs (Tirlc40. Pd6)
<br />Rcquind lx(cr of Norifi .arirn
<br />I c.nityrhr( rh. fcdrrtrlrrguhrtrtr)\ rclulirgn\bL{o\rrnnrxlrr. or nuluhl. hrhn tnjc.rffixtI havc rcad this .pdicalion ond \r!lc rhd rhc atiie inrnrflul
<br />, rL(,{ 11n,r tr' L i h.dc bx rclorin8 to huildinS con(rucr ion. ond
<br />nholc nf,nri{nrd pn)I[nt f,tr n\r.noi Nr
<br />\ppli$nl or ,\xrnr Silnnlu ) A"ts
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />L ight Standards
<br />Spas, Pool, Fountains
<br />S igns (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Faclory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Rouoh
<br />Ceilinqs (T-Bar Rouoh)
<br />Meter Release
<br />Rou gh </b E/lq 5.),--OlE-fiE x
<br />Service Meter
<br />FINAL b/2",4h >h69
<br />Notes, Remarks, Etc
<br />COMMENTS
<br />L.nd.i. ddr$
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