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ELECT ICAL.INSPECTOR RECORD
<br />APPROVALS DATE tD/stG.EoMMENiS OWNER BU!t,DEX DEI,CARATION
<br />I hcrchy iifiirn u cr pcnalry oa pcrjury rhar I m crcnrr fro'n rlt Cont,cror' Liccnsc liw lor rh. tnbwin8 rci{r (h( 70:ll 5
<br />Bu\incrs i Porc*io. CMc): Atry Cny r Counry which rcquircs s Frnrir ro co.nflcr, rlrtr. in9bvc. &nElnh "r rcF,t 5ny
<br />{flchtrc. prnnlo irs hsunncc. al\o rcqlncsrt. appltanr tn su.hpcnnir h nlc, siSocd (denrnt rior h.or \hc b li.cntd PUFuatrl
<br />b ihd povnhns of Lhc Cotrrachl\ Licctrscd ti{ (Cha!,lcr 9. Comrmn.in8 sirh Sc.riotr 7O(X} of Divisio. :l of fic ausin.ss .nd
<br />Pnncssiotrs Cod.)or lhat hcorshc iscxclnfl lhcrcr(Drnd rhc hrsi* ror rhc lcAcd.xcnDrion Anyviohionoasc.rion T0ll.5 hynny
<br />,pplicr rrtr r tnrnir subrcch rhc lpllicitrrlo acivilncnrlryofnor nDrc lhrn fivc h!.dicd dollnn(lissr)
<br />L as osncr ol rhc propeny. or fiychpk,rt{{ wilh wa8.s r\ thcn srb comNNalion. willdo rhc sork !M rh. srtrrurc is on
<br />ir cndcd nr oficrcd {o. el. (SE 7l)14. Burincs\ Md Pmfcs\nrns CM. l hc Conlrrlois t.i.cr{ I rw dot\ tror m,rly lo an o*ncr of
<br />rhc p'nr.ny wh, bxikls or inyroB rh(88 oxl who des sEh tr{'rl himsclfor h.rslfor rhn,u8h hn or hcr.snetnPk,y.c\.
<br />tnvnbd rlDr su.h imporcmnk trrc nor inrcrthl or ofi.rsl for qlc lf. h.!ctt. rhc tuilding or imPnttftnr ir $}l wirhn orc ylE
<br />ol conlPlct $n. rhc Owrcr truikls will harc rhc iud.n 6l poling rhar L or !h- drl mr buikl or i'npri,lc rh. In,ILiy f.t rbc pur,fc ol
<br />-l.
<br />r\.wner oirhc lopcny- r cr.lusiv.ly.onk.ri'rgwirhlr.ctr\crrcrnlrncloFt,..nstucrrlrlt,rccr(SN.7044-Btnrcs
<br />a'rl rh,h.sinC.dcrTIDCotrrr0ckr'sl-icctrscl-rwdoc\n.ixt,!lyk'adDwtr.rofptoPc,ty*hohuil&ornnPn,vcsIh$c..
<br />rd who onrruc(ror su.ht"riccrssirhrCankido(s)liccnsc(l nur!'rtrr rorhcCoitrcttr's Lkctr* Ijw).
<br />_ldmcxenpr ondu S.crion .B &P.C.lorlhnrca$n
<br />Dsle O*n.r:
<br />w()Rr(rRs contPl\lqrt)N
<br />DECI,AIAIIO!
<br />I hcrchy lffi rnhder rco ryorp.rluryoft orrhc rollowin8 dc.lafrriotrs
<br />-lhlveu
<br />* ill mrinhi. o CcniLatc ol C.tr$.r l. Scll:l trsulc for workcs' comtensorion- !&vidcdlorbyScclion:17(nolrhc
<br />ljlmr Codc. l'or thc perfonna.cc of rhc *olk for which rhc Fnnir is issued
<br />lhrvcrnd willmainrrin worlerr.onfcnsalion insurrn.c, rs r.qoncd hyStcti lTUrol llr lrhorCodc, r(rrhc0c hnnrNcoi
<br />rhc wrrk rur whi.hrhi\ pcnnil i\ i\{sd My \ukc^' ..nil.n\rri{$ ntr!tutr.c.adcrmd Policy nufitr arc
<br />-l.cnilyr[it
<br />ir thc perfiEunrt olihc *ork in whichrhi\ pci,nir i\ i\{td.l stull nor c Uniyrn, Pcrv)i i'r rtrynrnncr
<br />q, rsh hc.otu {hjdcr t,rhc woikc coq)ctrs.rdr lass.ic{liii,nir.,n,l r8r.c rhd ill shotrld h.conrc sutist rotk
<br />$orkrrr coq)c \dn,nF)v^ionsofSccrn llmo,lhc r,onrr C(xlc.l JEll.l.nh\rirh..nlllly wirhtho* nrovnions
<br />I4ARN|NG: Eilum ro scurc workcr' conpcnslion .ovcasc i\ utrharul. md shilr subitl on cmt'Ller ro aiminrl tf,mlras rtrd
<br />.ivil nn.s np r. om hundrcd rhousnd dolla^ ($100.001). in Jddirioo t' rh..on or.omJEtrs0tiotr. danuse\ ^ porid.d fr lhc
<br />Sccrnr 1076ofrh. tjbor Codc. intcErl and arrormy\ lecs.
<br />Drl.: {pplic.trl:
<br />r rr:rrrsrrx orirn rt ion
<br />DECI.dXAIION
<br />I hcrchyalfirm undc! Foalryorpdjury rharI r licc,sd u6J.r t,ovnhtr of Chrprcr , (commncing wirh scdion 70({)) ol Dienn,n l
<br />oi rhc Businc$sd PottssionsCodc. bd 'nr liccn* k in hilln*&dd.fltcl.
<br />IAISIBIJCUANIENDINCACDICI
<br />IlrcrchyaflnDundcrrcnllryolPciuryrhs hdtcisnon{ructionbndil]erecncyforlhcpc,romcorrhcwoikforqhic[lhnFnnirh
<br />tlucd (s( 109r, civ c.).
<br />AITIII;ANLIIiIIABAIIAN
<br />I rwr$y,trm undcr lcnally ofperjury{trc ol lhc,'ouowins dsl,rurj.n\:
<br />Dcn liri Pcrhns Asb.sro! Norincatn,n lidcrrl R.gul.r ions Onlc 40. Pan6)
<br />Rcqun d ldicrof Norificalbn
<br />I.crifyrl rhcltdcr lrcguhliof\ rclr'diDS rsh(d.!rcfnNrlx,r norqrtl.rDlc h rlr\ t)n)lL\r
<br />-l
<br />cdify th{ I ha$ rcad this trprlkarbn ald darc rhtrr rh. ah,!r inroflruri.n is.or(t. I r8.e lo comply wnh lll Ciryand counry
<br />ordinrnc.s &l Sr c tjws EUrin-q ro hoildi,s conslrudion. s.d h.rchy trurholiz. r.rc*nklncs oflhn Cilyand Colnry ro.6rcr utx)n rhc
<br />ftovc mdn md ptup.dy ro. i,rsrcction Nrlbsci
<br />,\DDln nl o.,\r l Sirnrltrrc
<br />I.miimntr.l|[inl):
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab i Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soflit Rouoh
<br />Ceilinos (T-Bar Rouoh),l
<br />lVleter Release
<br />Rouqh
<br />Service lvleter I
<br />FINAL V/zt/f &r
<br />Noles, Remarks, Etc.
<br />Pole Bases
<br />dL*tns/2///r
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