|
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
|