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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNElr BUIt,DER DELCARATI('N
<br />I hcrcby rfllnD und$ Nnally of |].rjury lhat I on .xcmfl rft'm
<br />'hc
<br />Conkn.ror' Liccnr rjB for thc lollowins reN,n (56 70:11.5
<br />Busircss .nd Profcsio Codc): Any Cily or Counry which r{uncs . p.nnll ro clnllrucl. altcr, improvc. d.mlhh or rcF'n any
<br />sto.rurc, prirto irr iss!m.. akorcquies rhcnpplicanr nn such Frmir k' filc! \igtul sdrdn.' ihnl hcor sh. is liccnEd !u.$!nt
<br />ro Ihc pmvhions of lhc ConlGtolx l-iccnscd Iiw (Chrptcr 9. ComNrcir8 wiri Sccrion 7(x)0 oa Divntun ] olrhr Busincs\ rnd,
<br />PDfe.\ionsCodc)orrhlr hc or shc n cienpr rhcrefromlrdric hasn for rhc alkscd crcmrrion Anyriolarionors(lionr0ll5brrny
<br />amlicxnr for a l]cmir s!br.{k rhr +llicDnr t, a .ivil l,.Mlry of nol mr. rhu fivc hxndrcil dollrs ($50O)
<br />-1.
<br />as osrc! ol rhc pmreny. or my cmployccs $ilh qa8cs as lhct snc conrpcn\slion- will do lhc sor{ a.d rh. strtm N nor
<br />i,trcndcd or orcrcd fir uk 1S.r 7044. Bu\i'res hnd lk,lcs\ions Codc: Thc G)nh.ror's Lkcnk llw docs nol rr/y to !n o{ncr ol
<br />Ihc tmpcny wtk)t ilds or iml,mls rtENn. and who d6 sEh m* hnnscllor hcnclfor rhmuBh his or h.r owncmplorcc\,
<br />pnridcd rh such impovcrnk m r inrcd.i o, oftcr.n nr st li h'w(r rtE builling or irqrorrnr i\ skl wilhin utu ttr
<br />of conroLlhn. lhc Owmr Builds *ill haE rhc l,urdcn ol proviry lhd lt or shc dit nor buikl o! ri\rmvc lhc lmpcny tu rhc purF){ .l
<br />L is ownd orrhc ptup.dy. ancr.lusivclycotrtr.rin8 wirh li..n\cd conr..ror lo consrucl lhe I'rojccl (Sr.'. 7Or4. Bd\incs
<br />and PFI$si,n Codc: The Conlr.ctols Liccnsc Law docs.ol upplyro M.*nc, ol propc.ry rh(, btilds or innrovcs rhc.con.
<br />rnd who c.nrft.rs for !u.h l)ft,Fi* wirh a Contucro(s) liccn\ed ru*usnr rotheContu lor's Liccns tjq)
<br />-l
<br />ifl cxcmfl undcr Secl
<br />D.l.: okm.
<br />W('RKFRS ('oMPEiSATI(N
<br />DSsl,a.EArp!
<br />I hcrct'yorlnmundcrn nlltyolpqjurloncoirnctollowin8dcclarori(nN:
<br />-lhrvcmdwillmrinr.in!CcrrificoreofConscnrtoSclf.lnsurcforwortcr'c.mpcnslrn,n,!sprolidddrubys*lionlTmorrhrtltxtr Codc, for rhc p.rfornErc. olrhc wor* for whdh rhc pdlnil i$ hsu.d.
<br />Ll harc and *ill nrirrnir {o.kcR conDcnsrlion insurancc. as rcquncd 6yScclior]700 o{rhc l-3bor Codc, rur rh psao.nBn.c oi
<br />lic work ior which rhisr.rmilis hsucd. My trorkcrs. om|xnsrron insurumcca cr aDd polny nu'nbcr rc:At/;
<br />6 t?
<br />-l
<br />ccniryrhit in th. pcrroirun.c oflnc work lhr which rhk ncflnir h hsucd. I shallnor cnpn,y lny F$oo i. any m,nncr
<br />$ k, bcom subjccr ro thc work.F Lx,iprnsdi,i laes orCrli{omia Md iCN rhd irl should tNom slbic.l tolhc
<br />workcc..nlrjnunrtdvhk,n\urSccrionlT0OolrhchlrrCdio,lshnll,fonhsilhcomlilywilhlhosprovhions
<br />WARNIN(i: Fnihr. ro {curc q.rkcr' omPrtrsdiotr .ov.rn8. is urhwful. 0nd (hrll sublcd or crqrlo}r! ro Eirninaili.nrkic\ md
<br />.ivil rinc\ un ro otu hr Jnl rhou\rtrd dolhr\ (\l(I).rXXr). i'l cost ofcomf.nsllion. daroscs 6 tn,vidcd ttt ric
<br />- S&rion .1076 or rh. Ltsr Gxl.
<br />&"., 5- 7-,f
<br />inlcrc{ and ormilry\ tccc
<br />--
<br />ArptloDt.
<br />DECI.ASAIION
<br />I hcEby afirm udcr I'cMlly of pcrjury lhal , !n licenscd u(lcr pmvisioi ofchsprd9 (@nmn ing eirh Sccrion 7m0, ofDivision l
<br />of th. BuBi6.ss and Ptufe$ions Codc.
<br />'d
<br />my lic.ns is in rull rn r nnd crcct.
<br />C- (J lao\o b )
<br />9""
<br />,('"( - 14 f,, c*r^"*,
<br />c()Ns'tllti('[oN I ll:tDtN(i acla\(]l
<br />I hcrchy arrn undc, Fmhy ol p.rjury lhar lhec is a .onsid.lbn lcndin8 lscrcy fo! rh. Morurc ot rh. eork for whih thn pcmir ir
<br />hsu.n (56. J097. Civ. C.).
<br />AIPIIIANI.DEqLAEAIION
<br />I hceby ,tim uidei pendry or perju,y om or lhc rollosing deld,! ions
<br />Dcmlirion Pcrmirs-Ashcsros Norifi clrion Fcdcral Rc8!lorions (Tirlc 40, Pln6)
<br />-Req!ncd
<br />Lcllerof Noriarclrion
<br />I ..niryrhar rhc r.dcr.lrcSuldioN rcSrdire a$.sos rcm,vrlrc mr aptli.ahlc to rhis lrojc.r
<br />-l
<br />ccniryrhd I nrvcrc.drhh !,,I1licirion md n arc rlFr rhc rtnvc nrlnrMri.n G cotrccr I trsr&!o.onfty*iihsllciry.fld Counry
<br />odimnccs flnd Sratc tj*s Ehrins ro buildi.E con(ructiotr. oM hcrch, (urhorirc repE\cnlnrnc\ orrhis Ciry Md Countyto cnlcr u,'nn rrt
<br />L$.rc nrnrtr,Nd rm|cny n flntFri' rrI[rFG.\
<br />Jtppri.rntorAaenrsr*MroF -k
<br />\ Pemirerume,prin.: L/*'.L l/'l
<br />I)=lS-
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilinqs (T-Bar Rouoh)
<br />[,4eter Release
<br />Rouqh
<br />Service Meter
<br />FINAL Ut/lq Sir 1\rFfi6
<br />Notes, Remarks, Etc.
<br />r,n,r,", 0l& t'-)-, z r. r,pn".,
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