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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNI'R BUILDER DELCARATION
<br />I h.dby affrn undcr p..uhy ol pcrjury lhll I m cxcnpl rmrn lhc Co reto Liccnsc Lnw lbr rh. {ollowins rdn\or (scc 70]1.5
<br />Busin.ss md PnlLssion Codc): Any Cny or Counly whicn rcquircs ! pcrn l ro on.ltucl, allci nlrlrovc. dcnnlish or (|[i My
<br />(rudu.c. Frk r to iis issuarc.. al$ rcquncs rtc applicsnr ior sch lcnnir ro lilc s sigftd ftrc'mn' fiar hc or sh. n lienscd llursrnr _
<br />nJ rhc pmvisiotrs of ltE Cookocrols Licenscd tiv (Chrprcr 9. Commncitr-q Bilh Sccrion 70m ol Divirion.l ol th. Busincss rnd
<br />Pmlcssions Code) o, thor lr or shc ircremfl lhcrcf,om lnd rhc blsis fff rhc dlcgcdcr.mprio. AnyviolalionofscclionT0:ll5hyao,
<br />{ppli.ani tu a Demn subirIs rh. applicnm ro rcivilp.mlryornor nRrhM 6vc hundrcd dolhs($500).
<br />-t.
<br />ns owrcr of rnc pn'pcny. or ny cdf,l6re$ wirh waEes as rhcn r.b conwnsd ion. will do lh. wo* r'lrhc sr*lr h to
<br />inr.ndcd or ollcred for slc (Se 7044. Businc* and Prof.ssirnr C.dc Tl.a Contndois Lien$ kw dcs not lpnly ro m owncr oa
<br />lhcp$F1ly *ho builds or nq'mrcs lhcmn. oi who {krs such wlk hnnsclior ncrrlforlhmu-qi his or hc.own cq)loy.cs,
<br />prcvidcd lhal such imrroEmnh @ not inrcn.lcd or.lteBl for sL.It how.u. rlE btrildi.-g or in{rokmnr ii $BrnhinoN )tr
<br />olcon{lclion. Ih Owncr Buitlcr will hovc rtc tx,lcn oa pmlins lh4 h€ tr sh. did nor lflild or irlll,mw $c lln rdy rnr rlx NrrxM or
<br />l. rs ownc. of rh. ,mpol,. amcxclusivclyco rncrinS with liccnscd conrracroF ro on{ cr rtE pnr..' (scc. ?04,4. Ausirc$
<br />rfrl lhli\\ir Corlc 'lh.(innrrnn \ I iccn\c l j$ docs norroply
<br />anJ $ho ( rr( lnr srchnolLr( $ir[r (-r fu.r,(\) lNf\.|)n,Fdy uhD huilds or irpnxcslhcrcon.
<br />.t
<br />'o
<br />rhc
<br />?rudds
<br />Licne rlw)
<br />;:-"4C /tc
<br />I h.rch, aitnrundcr Fn.lryollcrjuryonc oflhc followins
<br />I hav. nd willrtuinr{iirC.diftral..lConsctrr(, S.lf ln\orc htr work 6'conlpcnsdion. !s proridcd ir by SRridn .l7U) of rh.
<br />t.hor Codc. ,or rhc !.rl'onMnc. oa rh. sort aor whi.h rhe pcnnil i\ h\.r.i
<br />I hivc nd*itln,intoinworkcrscotrpcnsrlioninsurdNc.isrcquncdhySccrionlT(norrh.LlborC.dc.rdthc,tlfonMrccof
<br />rhc work f.r whrh tht pcrnril is hsucd My workcn' conrFnsalion insuEtrcc c!tricr ud Fnty .ufrb.r e.
<br />_l ccdili,har in rhc lrrlordnccof rh. work nr whichthi\ n rnn i\ hsu.d- I shnll nor cnrtlorrnyl}cnon in anymanmr
<br />$ N tJ b.coim subF.r ro lhc work.r' colqEnsrh l,ws ol Cnrifdnii. aM asrcc lhll il I should hecom sohj..r t, rrl
<br />*o!k.s' ..nD.nsDrion pottbni of Scci ion l?ur ol lhc Irtur Codc- I $011. lonhwirh .armply wirh rlx,{ pn,vist,ns..
<br />wAINING llil(c b {cuft workcr' con,!.n\Jrion.orcBs.
<br />. tr;l firc. Lj r , 'c hurl'.J ,h,,d. 'i J, lll'\ ,1llr,.irr,'. i',
<br />rfl cmploycr (' si'ni'rl p.'r'lrils a
<br />iotr. irnrngcs rs polnldd f(tr rhc
<br />Sccri.tr 1076 oilhc l,hr.Cod..
<br />"",", s/a&!r K
<br />I hcruby rmrm undd J*nilryofpcrlury rh r I.r li.cnrn undcr inS $irh S..iiotr l0(r0) ol Dtrisiotr I
<br />ol rhc Busilcs md Pn,Icssnn$Codc. a Nyli.cnsc is ir full f,r.c rl cilccr
<br />IAN,IIBUqIII)N.LENDIIIi.AGINII
<br />I hcrchy.finmuRlcr pcnallyotr.rjlrr rhlr rtqd n r rotr{rucri,)n hMirC tr8on.y f.r rhc p.Yloir.a.ce ollhc $ork ror which rhn Frmii i\
<br />hsucd (Sc..1097, Civ. C.)
<br />AIETQNLDECI.ASAIIO!
<br />I hfthydrr undcr p.mht ofp.rFryonc olrhc followinS dclealhtri
<br />Dcnrlirn,n Permnr Asbc{os Norincdion F.dcml Rcaul k,nx (Tillc.lO. Prn6)
<br />_Rdquicd trtr& ot N.riar.arion
<br />lc
<br />-l
<br />eniry lnal rhc fcdcrll rcsulations E-qedifls asbcstos rcDlul arc nor nprli.abh ro lhiq pmj..l.
<br />-l,.dlrrharrh6Fm,Jrhtr6r'r,lr(nnsrn{trhtf
<br />rh. lboyrintfrruhn i.c,'rer laErdto€mtlys hsll(il)on<l
<br />ordindnms,nd Srar. tlws Fhnnp r" burldtrRrorr*rinn. rn !iEb{.urrndr rclrrcrnhrivc. ol rhF Cly,nd counry rn cn
<br />ilil::::,il":-'w4%-=-- D." r/,.2/
<br />P.rm,Fmm.,pr,tro: J J,/
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lite Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Translormers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Solfit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />Rough LolglLq a lFrTr"lTC,1/,
<br />Service Meter YA
<br />FINAL \-L\-'u \\t\q)
<br />Notes, Remarks, Etc.w
<br />It/eter Release
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