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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS oWNER BUII,DER DELCARA]ION
<br />I hcrchy rilt'n utuls Ftrrlry oI ldrjury lhd I m cx.'nt lmn thc Co r0clorl l-iccnsc Lrw lor rhc fd[,*ins r.ten rt.c?0]15
<br />ausii.\s nnd Profcssion Crldc) Any Ciry or Counry *hich rcquncs a Frnir k' corsrflcr. lr.r. inlJ)mvc. d.n,lhh nr rclen rny
<br />srructurc. prioro irs hsumcc.d$ r€qln.s $c applic trr tu suchrci,nir ro lilci siSncd srltenEDt lhul hcor shd it li.ci*rl PuNxtrtr
<br />k' rhc nornions of rhc clnrlrrlois Licrnscd ltrw (Chapr.r 9. Cod'kn.ing sirh sccrion Tlxxr of Dilkion I oa lhc B!\incs\ and
<br />Pn,ic$t'nsCodc)orrhrrhcorihch.rcniflrhrrcrr.,ndihchr$sr(trrhcrllcBcdqcnllio tryrdarionotse.ri ?0ll5byany
<br />,mli.r r r(tr, !.rmir snbjcds lh. applicrnr lo iciviltctrihyolml morclhan ivc hundrcd dolhr (S5m)
<br />-1.
<br />!s owncr oI lhc popcny. or hy e'npbJtd Nirh al8es x\ rhcn n,b .omp.hal ion. sill d. rh( *uk m.l ihc {nkrm ( fr{
<br />intcndcd or orcrcd fitr sk lS( 7{X4. Busircs\ r,rd Pi.Lssnrr Codc Thc O,nl.acrois l,iccn\c hs do.s nor
<br />'lPply
<br />ln !n o*mt oi
<br />rhc pnrp.ny wh. builds or i'nIrlNB rhcN .nndw)[d(rssu.hwolthnnsclforhcrFllorrhnrghhisorh.rowncn oyecs.
<br />lmvidcJ rhir such impmvcnrnh aa nor inrendcJ nr onrrti for qlc ll how.vcr rh tnriu$P or i qmvcrEnl is q,H sirhin onc iur
<br />of cotrlPbrn,n. rhc Osncr Blildd *ill hiw lhc burdctr ol pruli S rh.r h or shc did trol ttrild or inlPtr'w rhc rmFly lor rhc puqx,c oi
<br />L r\own$ofrhc piuFny..incx.tusnclyco acti,r8 sirh licenscd conrrudor\ lo .tidflcr rlr FmFd (Scc. ?04,4. Suroc$
<br />atrd Prllasitnr Conc: 'l he Conrrcin s l-ic.nsc l-aw do.s hor dppl! ro anownct of pro,rcny *ho hlilds or inPn,vcs ihcron.
<br />.nd wh. ..nrm.ts ror such ,oicls wirh.Co mcrons) liccnscdrumranr rorh. Conrnckr's Liccnsc Law)
<br />ronKE&t(olrtENtiAuox
<br />DIIIABAIION
<br />I h.r.by arin undcr ,rMlir or rcrimy .nc orrhc b&rwir8 dLllafurnnr'
<br />I halc md will nxrntrain 0 CcniarcalcofConscnt to Sclf-lrNuEfor sorkri compcnssrnni. as Pmvidcd iorbySdion l7(Dofrhc
<br />litir C(xb, ror rhc pdrornrncc ofrhcworkfor whth rh. rcnnit k is\ucd.
<br />l hnvc rtrd willnrintrirl woIkcF conDcns.liotr insuraEc. r\ rcquired ty Sccrt'n:ITID ofrh. tjbor Codc,li'r lhc Pcrlonnancc of
<br />rhc $rtrkforwhihrhis pcirnit is is$cd. Myworkol compctrsarion in$rrnr caricruxl ,rrlicy numbct tc:
<br />Poli.yNunrt':r
<br />I .d'rily thrr ln rlN Irrtunnamc ofrhc trork lnr qhrh rh^ jtrnrir is rsrcd hnllnol.nrnkiy rtry ncnon i .nt trrnncr
<br />rhl if I \honkllx.o r nrhlcd torlr$ ,tk,hsm snbirr io rhc qolkcB' ..nltns0rion luwsofclliforni4 and
<br />workcri .omtlcnsiri{,npturixionsoISNlion3T00of lncLtrrxtraoJc. I nntlysirhrlx,r pmvhions
<br />/)
<br />|rilm n, ku.. $orkcrs
<br />n' .tu hun,lrd rlrr0srnd ollrr\ (Slrx).(,lX)). n ,-7
<br />'rrhc bhtrc9. hkrcq md flroarcy
<br />l-11' Appror,u
<br />I hcrcby iflnDn.dcr pcnrlryolpcrjury rtur I am licenwl utrdcr pn,vision orc .nnnmfl(irBwilhSNriu?(X())of l)ieisn,l
<br />of rhc Bx\i'rcssand PnftssionsCodc. nnd mvliccni. n ir nnl iorcc arxl
<br />I i.cnsc Cl.'\\
<br />,,,,. q'/t-/7
<br />I hcEb, aifrrh und$ Fnslty ol pcriury $ol rhrc is a.lnsttuclio. Lndi.8 agcn.y for lhc lfformfte ofthc sort lor which lhh I'crm h
<br />hsucd (Se. 3097. Civ. C ).
<br />AITUCAILDE(IJIAII!]A
<br />I M)y.filnn uMci p,.a[y of lirjry orc olrh.follo+'i.B d6.'hrariln\
<br />I)cnx,liri{ l'rnrirs A\h(ios Notil'icrrion Fcdcnl RcEuliriotrs (
<br />Rrquncd l.rr$ of Norti.didr
<br />I.cdrfy rhlr rh, fcdcril rcEularions rcFUdins ivrlr.. norrfflic$lr (, rl,A J,n)rLr
<br />_-t ccnifylhJr lhivc rcrd ll,h
<br />ortlinamcs snd Srarc Llws rcl i
<br />!e.r laEret,conllyqnhrllC[r.MC.trtrry
<br />Fsctrrarnts ol rhis Ciry r.d connry r. c.lcr upon rhc
<br />rlsvc nrlrxorcd rm|tnylir
<br />/"
<br />Applit trl or,\Artrl Sir$rlu Zera<L
<br />q-/f-/t
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Building
<br />Under Slab / Floor
<br />Bondinq / Groundino / UFER lLil^t, z -rr1^4r?+-o- ?lL/--\t--z;c ?ors
<br />Transformers ll'15/lq c-,b9.6
<br />Torqueing
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rough)
<br />lvleter Release
<br />Rough l'u6/k";\6
<br />Service [t/]eter
<br />FINAL 04tr/i\i\\(<
<br />Notes, Remarks, Etc.
<br />Communications Cable
<br />Sub-Panels
<br />I rn.cxunrnr u c' \c-rnn . B & PC for rhn cL. n
<br />nar. - ()sn.r:
<br />Irndcas Al,lrcs\:
<br />tt
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