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ELECTBICAL.INSPECTOR RECORD
<br />OWNEX BTIILDER DEI,CARATION
<br />I h*cb, af,irn undcr Fnalr, o, p.rjury lhd I m crcnfl rron rhc ConkkloN Li..ns taw |or thc f.Uowin8 rcas,n (Scc 70ll 5
<br />Busincss $d Pror.\son Cod.): Any Cily or Couoly *hich r.quncs 0 pcnnil ro onslrud, oller. nn ro!c- &hdli\h or tl,t tro,
<br />srruclurc, prior to irs issu.mc. aho rcqutcs lhcapplicant lor suchFnnn ro flc! sisncd d,re'rnr rrllrhcor\hc h IiNn{d IdF,{r
<br />to rhc pmvisions or rhc coolDcrors Liccn*d ti* (Ch,flcr 9. conrmkin8 wiln S.ction 70@ of Division :l of rh. Bu\incs rnd
<br />Pmfc$io.s Codc) or rhar trorsnc iscxcnpr rhcrelromandrhc hasn fo. rhc allcged cr.mprion Anyvioldrt,nofScclionT0ll.Sbylny
<br />appli.a.r ro..pfmn subjNt rhc aprlic0nrto,civilp.n,lryornor'Rtrcrh fiv. hundrcd dollds ($50o)
<br />-1,
<br />as owncr oilhe pmpcny. or mycmployccs with B,scs as lhcn {nc co'np..\dt,n- willd. rh. wolk ond lnc sltrturc s nol
<br />inrci&i or oltcEd li)r slc (Sr 7{}14, Busin.s snd Pmacssi.ns C.d.: Thc Conr|.ttr\ Liccns tis des nor lpply ro !no*ncr ol
<br />rhc lnpcny *n. hoil.ls or inrtDc rhc@n. srxl who docs trh vort hifrscl{or h.rs.lfor rhrculh hh or hcr own c,nployccs,
<br />pri,vid.d rhrr slch inprov.mnh oE tror ir cryled .r oltiNi lor sb. li h'w$s. ttr huilding or ir[tro!.ftnr iq v,ld wirhir .rc ]Er
<br />of.o'rflLri,.. rh. Ownd Buibcr will hrrc rhc burd.n of pmvi.g lhr h. or sh. did tror huild or inq,mlr thc l]I)tEny for rh€ luqn{ ot
<br />l. N.wn.rorlhc ptur.ny. n.x.lusivclycotdcringwth|i...\cJ.ofta.n"sroc.nsrucrrlEt)mjcclIS(.7044-Bu\inc\s
<br />..d Lblssir Codc: Thc C.nlrrlois Li.cnsc hw docs not opnly lo M owncr ofnrcFny *h() b!ilds or inptuvcs rhcrcon.
<br />rnd who conttuB fd such Ftulc.* wirh a cunh.kfG) licc.\cd pu$urm 11) lhc G)trrd.tols Licctrs Llwl
<br />I r r\Ltr,Ir tndcr Sc.r
<br />llaa6E8ll:!)lll[NssrloN
<br />DEEIdAATA!
<br />I hc.c$y rrTt.lrndcr lcdnlry.fpcrlurt otrc ofrlr follosnrt dc.lu.rio.s:
<br />l hNr ard aillnBifurir 0Ccnifi.ircolConscrr h Scllln\urc lir \orkcradnnrcn n,n. xs provi{tcd lbr iy S&r ioi :l7m of rhc
<br />ljh(r Cod.. f{rrhc p.rfornhi.. ofrhd rorl tar which rhc lcn rr n l\\ut{l
<br />-lhrvc,ndwillnrinrainwork.s
<br />compcns ion insur.rcc. $ lcquircdbySNrion:17{rotrhcliborCode.r rhc Pctloirnmcc ol
<br />thc *ork ld*nich$n |.irnil is nsucd. My workcs co'npctrsrtion n$uancc caricr and Fnicy nu'nttr rrc
<br />-l
<br />ccnilylhat in rhc pc ornnnccoflhc+'orklorwhichlhisncrmiri\isucd.Ishrllno'cnpk,rrnlBrsoninanrrlinncr
<br />n) s n, bcmm \trbjcd ro rh. workd\ .o'np.r\ ion hws or crlir,)m . Md aSrc rh$ ir l should bc(m \ubjcd h rh.
<br />so crs (nnp..sarn,n!rt,visionsorSc.riofllTlDofrhrLdbrC.dc,Ishall,fonhairhconrtlyairhrhotnrovi\i,)is
<br />WARNINC F'0iluro ro *curc *ortcr conpcnsarion svcrasc is unla*tu|. ond shall bJ€.r an .'nplDttr lo ni.rinal p.n.lrts a
<br />civil fincs u! lo o.c hundrcd lholsnd dollar ($luo.oolr), ir addirion ro rhc.oi or..nFnerion. d0m8cs rs fiovntn tnt rhc
<br />S(rion 1076 olrh.lilfl Codc inrncd and dt,ft!\ fes
<br />D.le: {rDlienl:
<br />r I(txNsFn cI)NlTtc_IoR
<br />DES.AAAIION
<br />I hcrby,mrnunder p.Mlry or p.rjury $ar I !m lian*d u.d.r povisionofChiptcr 9 (ommrcins Birh S€dion Tmol.lDivhion 3
<br />oI rhc Busincssdnd PmLssi.rrCodc, rnd my lkensc is in tullfo.c!ndclLcr
<br />Ltcn$ Nunb.r:
<br />Controclor:
<br />CONIiIA!]CIqIIIIDIXC.AGINS
<br />I herhy alfirm undc. rEoahyorrcrjxry rhd rbcc is u conntucri,n Lndins,scmy ld rh. pcrfonmncc oflh. rork tu shichthk p.dir n
<br />hsucd (Scc 1097.Civ. C ).
<br />A.TTT.ICANfDECI,IM.III}N
<br />I h.r.b, amnn u nder pcnally of pcrjlr, om of thc aollouin8 dcclanlions
<br />D.mlkion P..miB-Asb.sos Notificalion rcdcml Rcsuhlhns (1 itlc 40. Pan6)
<br />-Ralircd
<br />t rlcrof Noliarlrion
<br />I.cnifyrhrrrho frd.r lrcsuldlioN eSording Nh.nos rctu)vrllc n.rapplic$lc kr l[istn,rc.l
<br />I ccnify rld I lDvc rcnd rhh olplicnrion lnd (ore rhlrrhc abole inlorrorion i\ codr.r. I rEd t, cdmply wirl lllCily!trd Coury
<br />ordi.rRcs,nd sturc Liws rlarirS to buildin8 coflsrocthn, mn hcEby iudoriz rre\e0rarilds of'hn Ciry 3nd cou.lyio cnlq ul'on ltE
<br />ahvc nrnrn'ncd prop..ry fu iNp.crionpuirsr
<br />Appli(rnl or A8enl SiaElure
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor I t
<br />Bondino / Groundino / UFER (//4ru
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rouqh)lr
<br />b 7,L \q ,ua.<D
<br />I
<br />Rough
<br />Service lVleler
<br />FINAL ,2Wri
<br />Notes, Remarks, Etc
<br />s
<br />lvleter Release
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