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ELECTRICAL-INSPECTOR RECORD <br />OWNDR BUILDER DELCARATI('N <br />I hcrcby afltm lnder pcnrlry or p.rjury th0t I m cxcnrlr riorn thc C. racroF Li..nsc Lrw lor lhc tdlnwing rc.$n (S.c.7oll 5 <br />Bu\inc$ ud Prorc\rn Codc) Any Ciry or C.unr, whicn rcqut \ r Pnnir ro on\lrucl. ahcr- intlovc, dcmlish or rcI)6t lny <br />{tu.rurc. pri, b ns issulncc. alw rcq tcsrhc applicanr nJr su.h r.iIlir to ljle a stncd ndcmni rharhcorshc is lic.n(d lxhxr.r <br />ro rhc rovisi,,ns ordr c.nk0.rols Liccnscd kw (Choflcr 9. C.nrmncine Rirh Sccriotr TtxD of Divhion I olth. Busim$ rnd <br />Potsnrn\ Codc ) o. th,t rEorshc iscrcmfl rhcrclroddnd rhc blsis ror thc trllcScdcrcmflion Any violdion ol S(lion 70:ll5 hydny <br />appli.rN lorap.n subjLrh thc rpplicrnrro acivilpcfrlryofnor nnrc thrn tlrr hrndrcd dollars ($5u)) <br />-,. <br />$ o*tur .f <br />'hc <br />pniPcnt. or n1y cmtloyes qnh w.scs !s lhct slc .oq).nsar ion, will do r r0rt dnd rr. sanuE n nol <br />i'nd.d.d or ofic.cd ror s.lc(Sa 7044- Busine$ rnd Preacsrion\ Cdr.: Thc (tnltrcktr s Ltcci{ ljwd@smr a!/y ro s. osrcr ol' <br />rh. lrlrny who builds.r inpbrs rtlmn. and who des Mh mtt himselrdr hc*.lrot lhmuSh hh ot hct ow.employ.cs. <br />ptuvidL\t rhar such nnplNnEnls@ mr i'ncricd or ortcrsl for slc.ll h.rcw. rhc hoildins or impmwntd hM,klwithinom )car <br />of..nllhrbr. rtb O*nft Buillcr willhatr thc burdcn ol povinS rhat hc or ihc diJ d huikl or iflr|)orc rhc PNncny Lr rh. rntlb* of <br />l. n( ow cr oi rhc |[rlcny. !n .$lu\i!cly conrracr inc Nirh liccd*d .orr..t,)n n, .on{rurr rlt Pi,jdr (Ss 7u{4. Bu\ims <br />onn PDhsh(idc: Ihc Conkrttr r Li.cnsc Liwdoc! tror iprlyro ano{rcr of tm)ll' ywho huilds or imnrovls rh.rcon <br />rnd shD.. nch ror su.h rnjcch *nh a Contachn r li.ci{d fuN'nnl t' rhc C.Dr,ackn s l-irn$ Lrv). <br />I n cx.nut uftlcr Se-li{n <br />lo8tr[rlli-roufr lallaN <br />OECI"AaAIION <br />I hcrcby afitn undcr pcnahyotpdiuryonc orrh. rollosi.f drctdrrions: <br />IhrvcnMwillroinriorCcniilcar.ofC.n\.nlt,sclf.lNurclorsorkcnconrpcn\arn.asPtuvidcdl'or6ysNrn,n]7molrhc <br />('od.. r.r rh. l.lfonM.cc nllhc work ior uhich rhe pcnnir i\ isucd. <br />!.d will mrinhin wor(cF comlc.\ri ion insurM.c. r\ r.quired hy S(l ttn 17{)o or rh. hhor Codc. lor rhc p.rformn.c ul <br />01 <br />f'1t smpcn. nrn nrumrc carEr anl Fli.y nunb.r sc: <br />2-r){0 <br />-l <br />ccniltrhd ii lh. Frronrrrcc ol rncNork r'or whkhrhi!F-rmir is isrcd,lshrlln.l cmnkrrrnrrcrv)n ir rny n'inrcr <br />\, .\ r, b..!m suhjccr k, rhc wo*.6 .nnlpcisrii(n lrws ofCililornir and agR rhd if I \tu,ul'l tf,com suhFcr h rh. <br />$oAq\ conrFnslrionprcvi\ions ofs(xotr 1700ofrhc tihtr ('frlc.l shrll, f'dh*irh c.nnly silh tli,c pmvnn,n\ <br />wARNtN(;: Fnihr. to sccurc workcn c.mpcnsrii('n $vdhB is ufll.*tu|. nnl shull \nbii M cn['bycr lo sini'lrl p.mhh\ trtrd <br />.ivil iltrcs ut ro onc hundrcd thousrfti doll4is (Slm.firD. in rdilhkn! ro rhc casr oi compcn\rion. danuecs as Pn)!id'd r'r rh' <br />:";'6i?rji:sll <br />t)t.( I \lr \ llr )\ <br />I hcrc$y oriirnr undcr pcnalryorrcdury lhal I am li(nsn und.r pnvnbn ofch,lrs 9 (commmins Birh S..rirn TulO) ofDivnioi.l <br />or rhc Busin ssaM Pmfe$ions Code. udrr licc.s. is,ntullforcandcller <br />:::5[ <br />b <br />t <br />C(TNS'TRII(]TIoN I FNDING AGENCY <br />I hcrhy,farn utrdcr ltnrlly of pcrjry rhnr Ihor. is0mtr{ru.rion lcndirs asctuy nr rhc p.rloirMmc oflhc work i(rwhi.hrhh rnn n <br />hsucd (Sec 1097, Civ. c.) <br />d.TTLICANLDECIABAIIIJN <br />I lmhynfinnu.dcr llcnall, ofpcrjury onc orrhc followinS ds..le ions: <br />Drm)lirion P.rmirl Ash- os Nolilicolion Fcdcral Resrllrtns (Tnh,$. PM6) <br />-Rcquircd <br />lirrd of Norift ,tiotr <br />+lccrtllylhil rlr l.d.' rcXUhri(r\rt'!r'dirEi\lE{o{rcoNvalr.cnorrpfLi.rhlcr)rlri\l)(,rccr <br />yrhlr l hnkrcadrhisapplic0lioru (rlclhallhcrh,r iihnn:tri(r hcorccl I oarero.oidr"wirhallCir)r Counry <br />snd Srrr. uss dLItlg b h]ildim co.(nrcrion. rnn hcEhy atirxtr,c rcprcscnlalircs ofrhi\ Cnl trM Cnunryro cnrcr ul'{,n rh. <br />APPROVALS ID/SIG.COMMENTS <br />Site-Work <br />Underground <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Sions (monument) <br />Lile Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Building <br />Under Slab i Floor <br />Bondinq / Groundinq / UFER <br />(Transformers <br />Torqueinq <br />Sub-Panels ?)\Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinos (Hard & Soffit Rouoh <br />Ceilings (T-Bar Rough) <br />Rough <br />Service [t/e1er I <br />1)FINAL LlLh\r$,,Ulthft <br />Notes, Remarks, Etc lr <br />Irmilft nome(prinl):i\q fo <br />DATE <br />Communications Cable <br />It/eler Release <br />trndfl . Addrq _ <br />,,,.,51611L <br />I