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ELECTBICAL.INSPECTOR RECORD
<br />APPROVALS DATE COMMENTS OWNNR BUILDNR DELCARA'TION
<br />I h.rcby rifin! undcr pcnalry ofFlury rhar I dr.renpr fr,nlrh. Conkr.ttra Liccns. Law l()r lhc I'ollowir8 rcn\rr lscc.Tr-ll 5
<br />aurn.\s od PNfc$ion Codc): Any Ciry or County shich r.quncs ! pnrir b connrucl, llrcr. inrprovc. dctrx,lhh or s|un ,ny
<br />drucrurc. lIi,ro irs Gsuucc, ako rcqutc. rhc lpllicanr itr suci Frnir io fihr si8n.d {aremhr rhd lrorshc s li.cnscd ,)u6tr.rr
<br />lo rhc pnrvision( oi rh. Cotrlr.ctofs Liccnscd Law (Cn!|]lcr 9, C.nnncrcins wilh Sccrion 7(x)o oi Divirion:] orrhc Bu\inc$ and
<br />Pbfc\\ions Codc) orrhar h. or shc i{ cxcmpr rhctofroh dd rhc hasis for rhc dhgcd cicnl.)rn,n. Any rtr ion ol SLrrinr 70ll l hy a.y
<br />rpplici rbr rF.mn suhjdsthc apflic,trt lo 0civilF.oltyofnor NrcIhr livc hundrcd dolhF($500)
<br />-l-
<br />!s owmr oi lhc t'opcny. or my cnDkryccs wirh raacs as lhcn sob NrrBnsali()n- will d. rlt lolk .flI thc i tufl is mr
<br />inrcndcd or ollcrcd ln qlc (S( 704.1. Busirr.\s and horcrsn,ns CGic: Thc C.nka.r.r's Lkcn€ bw des ml 0!dy ro 0n osncr o{
<br />rhc nmrEny who hoilds or iuoB lhcNr.0.d sh. dfts srrh {ori( himscltor ncmlf or rhmusn hh or ncr own.ntk,ye.s.
<br />t'iovid.d rhdr skh inpior rnts dc nor inrcfilol .i ordcd f$ sL. lt how.vd, rtE huiktins or iirr,n,rcmnt ir hll rirhio om rur
<br />.f.o'rpLrion. rtt Owmr Buikkr will lar rh. burdcn of lmving rhnr h. or slc dit mr huild or in{mrc lhc tmp.ny for Ur !'uqn{ o,
<br />L N uwRi of rh. ln,rdy. im cx.lusncly conrkrinB wirh liccn\cd conrlcror r, con(rucr rhc preJsr lscc ?044. B!\inca\
<br />Md h.,tsionCodc:'lhcConrdoisl-ic.nscI-Jwdoesnorapplyroano*nc'ofprcpc ywh{' huildsor iinprov.s lhcrotr.
<br />rtrd alar R) Bds fn such pmF.ls wirh. (tnrtuclo(s) li.cnscd |)u6uotrr ro rhc Conlructoir l-iccrsc Li*)
<br />-l
<br />amcxcmrl undcr Scdn,n-. B & a.C lor rhil r.asn'.
<br />Dnle: Oqner:
<br />rvoRKERS', Crr\rPEltsATt(lll
<br />DICLABAIIO!
<br />I hcrc$y.lfiDr undcr pcmllyolpcrjury onc oflhc nnbsinB dcclanrn,ns:
<br />-lhovcandwillminr(in!CcnificlrcolConsctrrroS.liln\ureii,r$orkcn.ompen{rnnr,,srmvid.drorbyScctionlTt[oltheLohor Arlc. for lhc I'.rfoamnN ol lhc work lhr Bhich lhc lsmil n issucd.
<br />-lhrvcrnd*illmlnoinwrk.rrc.'npcnuiioninsurancc.asrcqrtdhySccrk'n.lTln.frhcL,borCodc.forthc|ulhrunccolrhc wori nnvhichlhis pcnni! is i\\ftJ My*orkcrr dnnpcnrrri,r iNdraxc.adicr tull B)lkyiu rhcr rc
<br />c,ni"., r € x€ r7'r P1'
<br />I ccnifylhnr ir rhc r.rfo notrcc ol rhc w.r* Lr uhich rhis pcirnir n h{cd.I \halln.r c.rtnry,nt p.rs.i ii rnyntnncr
<br />$ a! r,, l,conE sub]ccl ro rlE *orlcr' q,hpdn\arn,n hws oi Calilornin. dnd .Bruc rhd ii I $.uld tr..nE subj.! h lhc
<br />sorkcr\, <,ma.nsflrion pFvhiois of S.d n,n ]700 of rhc ljtnr Codc, I shall. f.nhsnh c.nllly w irh rln$ nrcvkiotrs..
<br />WARNINC: FJIurc ro scurc workcs com|xnqrid corcrn8c ir unl.Ntul. and \nall cnDl,)ycr n) .n riirl ltnllk! itul
<br />i0,. ,lxnaSc\ n\ |m*nlcd tur rh..ivil ftrcs up k) onc hundrcd lhou{rnd dolhr ($l(x).t{x)). ir
<br />S(rion 1076olrhc bbor Cod.. i.tcic, and dtonEy s lac!:l/z-llLr ^ppliotrt:>l-
<br />DF'CINRATION
<br />I hcrchy aflirmundcr pcnalry of F.rjury ih.r I un! licdnrd uodcr povhion olChrtln 9l.omnEncing virh Selhn 7000) ofDivni.n.l
<br />oI lhc Businc$ rnd Profcsions Codc, ird my liccnsc is in ltllfore rn cffecr
<br />Cto 4365/-o
<br />3 a! * .-,-o*,pZ-K_>
<br />CONjiIII]IIIONIINDINC.ACENCI
<br />I lrcrcby 0flirD u.dcr ncnaltyolpcrjurylhol rhcrc t a con\rnrcti,n lcDdi.s qcncy h,r rhc l].rronrhrc orrhc work ror Nhth thh Iicrnril is
<br />isu.d (Sc. 1097. Civ C.).
<br />AIILICAILDEIIdXAII!}N
<br />I hcr.ny ofim u nder lcnulry ot Frjur, onc 6t rhe follo*in8 dcclml ions
<br />D.mlirion P.nnirrArhcios Notiic.rion Fcd.ral R.Sulrrions (Tnb 40, Pan6)
<br />Rcquncd llner of Norificdirn
<br />lccnilirh i lhc rcdcolrcsuliri,ir\ rc!rr'lirs x.6(\lo\rcnnnnlirc nor rr0li.rhlc h rhn tx),c.r
<br />lZ{"en:,ry wr t tr* rca u*appri.lrio. md sht. Ihar rh. dbovc iniormr
<br />orZ<tV
<br />to conDly wirh ull Cny,.d G,xnry
<br />rrhn Ciry.n! Counlyro cnrer uBrn rhc
<br />,,.,,, .?/*q//9
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />L ight Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Lite Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Bonding / Groundino / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Solfit Rouoh
<br />Ceilings (T-Bar Rough)
<br />It/leter Release
<br />Rough
<br />Service Meter I
<br />FINAL ,/o/o?/z 74+'Lr/ )
<br />Notes, Remarks, Etc..,u
<br />-+
<br />rD/srG.
<br />PolicyN!nbcrLExpncs:
<br />L.ndcr. AddEs.-
<br />orliranccs rnl Srrlc Lrw\rchri'rgb hrild,.!
<br />abovc nrfioncd pmrcdy for in\I(rion
<br />+ltqrb
<br />Under Slab / Floor
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