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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondinq / Groundino / UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinos (Hard & Solfit Rouqh
<br />Ceilings (T-Bar Rough)
<br />Rough 1\1L\\X,/r ldr'l
<br />Service lvleler
<br />FINAL //'-/f/g--zV-ltsr 'fbrz-?/
<br />Notes, Remarks, Etc
<br />OWNER BUILDER DEI,CARATION
<br />I h.rny ar6rm uMcr p.tr ly of !.aury thal I m cxcnry rmrn lhu cotrt .loE Lkcns tiw for lhc follositrS rcasn ls.c.7ol l .5
<br />tsusitrcs nl Prolcsion Codc): Any Cny.r Counly shth rcquncs , Frmil ro onnrucl. 0hq- imrmr. dcmlish or ErEt ,
<br />srtocrlrc- prir ro irs hsurmc. !l$,cqlircs ricryplicrnr ior suchrermir to filco signed rrarcnrnr rhtrl hcor\hc il liccn$d pxnu{r
<br />ro rhc p$vnions ol lh. contacrol! Liccnscd Liw (ch,flc. 9. conrmncirS eilh Scclion ?()()o of Division I or rhc Bu\inc\i u,l
<br />PronssionsCodc) or lhar hc.rshe kcrc'npl lhcrcflom.nd lhc b.sis for t hc allc8cd cxc mpl ion Any liinarion o, Sdion 701I 5 by any
<br />afi,li.lnrfor{FrmirsuhjccrsrhcDpnliQmt,r.ivilpcnllryofnor nrcrhm l_rvc h"nd!.d doll*s (!;5m).
<br />-1.0s
<br />owncr ofrhc nmpcny. or mycmDlo)er virh sa8cs as {hct slc contEnsa'ion. willdo rh€ sork {d dc nturm n R
<br />inrcndct oroircrcd for slc (5(.7044, Bu\incs nnd hofcssiotrs Codc Th. Coirrrttr'\ Li..ne ljw d..s nor tpply ro M on'ftr ol
<br />lhc p$Fny vho hoilds or i itfl)s thcu)n. dxl who ilo.s such *,& hims.ll or hcncll.r rhmugh his or hcr o{tr c Dloycc\.
<br />pfuvidLal rhrr such inpnNnrtummr inr. lcrl oronbftl fir sk I[ horos, rhc hriUin8 nr imprcwn.nr h s,ld wirhin.k ltd
<br />ol.ompLlhn. rhc Owncr Ruildcr * ill hlE rhc ho.dcn of lr.viry llul hc or shc did ml tdild or irqrrorc 0E pmlcny for rh. purlr,* or
<br />Lr\owncrotrhcpn,tdr.a'ncrch\ivclyconrncrinE*irhliccn\cd.ontackn\r'd,n{flcirhcpn,r.cr(Scc.1(}14.Busirtrs
<br />afrl lh,lc$i.n Codc Thc Contracnn s Liccnsc Lr* docs nor rl)Plt lo rn owB ol rrop.ny tr ho huild\ or imr(Nr\ rhcr.. ,
<br />rid (ho co rach fff soch pnJjmr\ wirh a Cu Dcktr(s) liccnscd,rBua r k, rhc Conrn.kn r Lt.nsc bw).
<br />-l
<br />o eicnrfl !ftlcr Sccr
<br />I hcrcby rfirtrrundcr |xnrlryoi
<br />DIiCLrnd[rN
<br />Ih.v.ad*iltfrrinrrindCcnifi.dcolConscnrros.lr-lnsur.f..wolkcs coqEnsarnnr.0r providcd lor by Sccri.n]700 of rh.
<br />bhix C{dc, for rh€ performicc oI rh. wolk for whki rhc Frfrn i! issocd
<br />_l hrvc 0nd willnraintunr worhcn compensaln'n iNurnncc. rs rcquncd bySccli{,n 3?(Irol'lhc IihorGdc. ror lh. l)crLirmrrr or
<br />rhc Norl forwhichlhn pcn.it is tssd My rortcr' con{'.nsd ion insumncc clri.r,nd Fnicy nrobcr e:
<br />l.cniry rhar ii rhc l.rfonn.trs ofdr work fd whi.h ihis l.nDir is irsu.d. I shrll nor lnploy.ny 0cron in rny mlnncr
<br />s a!lo hc.onE $rh]cfl lo rh. sortcfs conrFNalio.luws ofcaiifolnl0- ond asre lhar if I \holld hcom suhiecr nr rr*
<br />sorfici\' cinDcn\orion prclilions oI Sdion :l?(Il of lhc ljtnr Cdq I \noll, iodh*irn <,mply sirh rby rmvisk,ns .
<br />WARNIN(; F.ilurc to s.nrc p.rkcn'coDrpcD
<br />civil lincs ut r(J om huidrcd rhousrnd dollnrs
<br />..vcnrc N utrltrwlirl. ud lhrll snhj..r rn cnrplorcr ro ci'ni'[lp.D]lric\ and
<br />l0o.(xx)). h rddkion to dc cosr ofcompcnsltion. dom8cs a\ proliicd tor rlrc
<br />Ihcrcbya irnr u cr pctrolryofpcrjuryrhll Irm liccn$d ptuvirior oiChqrlcr 0 (commminE Firh Sccrbn 7(rX, ofDi!(ion.l
<br />oI rhc Bd\i',.\\ rnd Pfl,rrssi{Dr Codr. n' trir- liccn\c n i', tullturr klcflccr
<br />rctr'c Nunrhcr:
<br />-
<br />C!)XIIIBII(:IIONIENDIN(i-&ADNqI
<br />I hcrcl,y rfnrmundcr penllty o t pcrjlry rhd rh6c is! on$ruclhn lendin-q as.ty ttr rhc Pjrlummc or rhc work ror which lhh tEmil 6
<br />tsucd (Scc.109?. Civ C.).
<br />APILI!'INLIEIIABAIIO!
<br />I hcrct y i1fm undcr pcnally ol,rerjuryonc oflh! iollowinS dcclmlnrns:
<br />Drnn,lirn,n Pfnrir* Asbc os Noriflcdion Fcdfi{l RcCtrlarioN lTirL lu). PM6)
<br />Rcquncd btr.r of No frdirn
<br />*,,/J
<br />',M"?h\{'1
<br />l'l rhc icd.rrl rcguldtnN rcE{Ji,rS ish.do\rcnurlrr nor rpplicrhfu t, rhi\ n'oj.cr
<br />lhavcrctul rhisrptli.[i,r md srJcrhar rltr rtr)vc intuirndion isc.nccr lrBrerocomplrwirhnllCiryandCounry
<br />s.otr{d.tioi. d hrrcbyrurhorirrc,'rcscnl ivcsoflntCiryandCounr,ki.trrcrrF,nr}E
<br />(-i 6 W^r-
<br />,.,"q:?5-\B
<br />Meter Release
<br />t ndcr'" Addr..i
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