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ELECTRICAL.INSPECTOR RECORD <br />OWNER BUTLDER DELCNNATION <br />I hcrcby !flirflr undcr pcnahy of Frjury lhal I om cxcmpt fnm lhe Conllacro6 Lactn$ bw roi th.lollowitrS rcason.1scc.70:11.5 <br />Ausinc$ lnd Pmfcs\ion Code): Any Cn, or Counry $hich Eqoncs , P.mi! b d)nsrrud. ahr, ifrPrcvc. dcmlnh or.EFn an! <br />slrucru.. prirb ns i$ua c. dsor{utcs rhcnplli.ant tar s!.h pcrmit t' filca signcd \lslcmnr rhar h.o.rhc is li..n{n Nnutlr <br />lo rhc pmvhn'n\ olrhc Conh.t, r l-icdns.d ljw (Ch,nrci 9. Comnrrcirg with Scdiotr ?ur of Divnion :l ollnc Bu\ilts and <br />PmLsri,rn Codc) or Ihd t or shc is uxcmpt lhcrcfrom md rhc b0sk for lhc allescd crcmlrion. Any vblarion of s{rb. 70-l I 5 hyany <br />.lplicanr lor a Frmir subj(ls rh. amticonr to a civil pcoahy ot nor rurc rh fiv. hxndnd dolllrs (Ssu)) <br />l. ar .wNr oirh pmp.ny, or my cmployccs qith wascs $ lhcn sot qn.|.osrlii,n. will do rtb woA .nd lh. stnrlurc is nol <br />inrcndcd or ofcrcd ld $lc ( Scc 70'14. Bu.in.s 'nd Prcfcssn'nr C.d. Thc Conlra.lor's Licctrs trs d€s rer E ply ro an o*icr ol <br />rh. nstx y Eho boilds o. in$ma rtr@n, arn wno des sxh $ofi himscl, or hcB.lf or rhbuah hh or h( own c,nPloyccs. <br />pn,eidedrfinr srh nqrokmnN e nor inr.ndcd or ofrcR:l for sh. ll <br />'xBcvs. <br />lfu hu illillg or iqmkDni h v,ld *irhrn onc ytru <br />olcorytri{u rtr Owrcr Buildcr willhlr rhc bldcn or pmvins rhlr hc or shc dil mr t iU .r inpmw fic pop.ny for rhe plqiE ot <br />_l-!sowncrofrhcpnrn ny.aflcklxsivclyconk rina*irilic.nscd.otrtnroNro.onstrucrrhcnmjcd(S(.7llr,r-Busincs <br />0M h!tr\si)r Codc: Thc Conlrdols Li.cnsc tiw docs nor aplly lo !" o*mr otproFny wto bnild\ or inprovcs dcrcoi, <br />rrd who onrmch li,r slch pn iccG wirhrC.ihcrtr(\)liccn\cdpununnl k,thcConaclols Liccnrc L3rl. <br />I r .\rn,tr trnd.r Sd(l(rr a & l'(' ktr rlri\ r.nnrr <br />l).lc: (hrnrr: <br />]{aa6EB$-loMt[!larl0N <br />DECI.ABdIIA! <br />I hcrcby ailirtnlndcr p.nahy.lpqury.n. ofrhc ft,llownr! d(ldrdrion\l <br />_l h!rc ud will mai'rrai', r Ccnillcrrr ofCon\cnr h Sclf lrrur r{, sork.{ omt,utrsrli,nr. a\ pnvidcd rir hySd.t'.n l?(X)ofrhc <br />l-rh)r Grlc.lor ihc pcrtirmtre olrhc *uk for $hich rhc pcnnir n i\rucd <br />I hnvcr.d will mainrdin r.rkcrl c.n[cns0lion ,nrur.mc. is rcquircd t y S(l ion :]7lx) of rh. lihitr Codc, for rhc 0.rlonnncc of <br />(h. w.rk lilrwhi.hrlris pcnnir is kscn. Myqorkcs conr|[trstlotr insurnncc caricr md roli.y nu'nhcr dc: <br />WARNINC l.lrlurc b ccure solkcr comp.n{riotr corcrrg. is nnhwlul. and \hdl \ubic.r ,r.nplo}er to crininf,l Fn,hi\ md <br />civil nn$ uD nr onc hundlcd rho!\and d.llrs ($llD.lx ). in addnbn k, rhc.oi.fcompcnstrtion, drrm8c\ a\ tbvil.d it rhc <br />SNrion -10?6 olrhc Lltnr Code, iircrcn aid anonrr\ ree\ <br />Appllonl: <br />ltc[NsElll;lNr8agrof, <br />DECLAf,AII9X <br />I hc(by ltfirf, undcr pcnJtyorp.rjury rllal Ln lienscd undcr lrovisiotr olChuprcr 9 (srhn-h-'ing *nh Sc.ridl7000) olDivnion 3 <br />oI rh€ Busincis and PFlcrshn* codc, rid my ltcn* is in aull lore rnd crlccr <br />I!]NIIAUqIONIDNDINGIAENCI <br />I hcEb, rfnrm undo F.alry ot ,ctury lhd dr.. k a con{rud hn tndin8 lBcncy for ric pc.io@ie ot rhc *ork for which lhh rrmit h <br />hsucd (SN :1097. Civ. C ) <br />AIILICANIDECIdAAIION <br />I hmht rmrm undcr pcnrhy of pcrjury onc oflhc following dccleolions: <br />Dcmlnion Pcrmih Asbc$$ Notii.ariou F.dchl RcSnlarions Onh 40. Pan6) <br />-Reqlircd <br />kn$ o, Ndifraron <br />I.cnrfyrhd lhc lidrnl rcSulati(nN rcgtlal,n8 rstE$srcNrr!nrc Nr rnpli.rhlrt) rhi\ fl.1..r <br />_l ccnity thar I h4! rcod rhh aptlic,rion,r*l Nar. rhd rh. alblr inrdnrlion iscomct.l asre to cunply sirh allCiryand Couflry <br />odinanccs lnd Shrc Ldws rclurins ro huilding cnnsrru.rion. sDd hcrcby,urhrizc rcfl.snl0rivcs oilhh Cilyond Cour, x, cme uF)n $. <br />0tnvc mnl iDftd ,rcpcny for itr$cction purFscs <br />,\ppliuDr or,\trDr SiItrxrurr <br />APPROVALS DATE ID/SIG.COMMENTS <br />Site-Work <br />Underqround <br />Pole Bases <br />Lighl Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Salety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bonding / Groundino / UFER <br />Transformers <br />Torqueino <br />Sub-Panels <br />Air Conditioners <br />Rool Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilings (Hard & Soffit Rouoh <br />Ceilinqs (T-Bar Rouoh) <br />Meter Release <br />Rough <br />Service IVleter .rffiFINAL//zrt/rY <br />Notes, Remarks, Etc I <br />Drr.l <br />(-J"i,1 <br />I ftnify rhar in rh. p.rfonM^_c ofrhc work for which rhi\ prnnir n G{,cd. I \hall nor rmpbt lny P.ron in iny m0nrcr <br />{i $ r, tEmnE subjccr n) rh. worken cumpcnssrnnr hss olCaliirnia. Md asm rh il I druld icconE suh,cd hrhc <br />workcN compcnsati pn,vkiomofSccin,n:l7UOofrhd If,htr Cod..Ishnll, fodhwirhcon ywirhiho*ln,visionx <br />L1'lc,'\ AJd,c.. <br />I <br />I