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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS IDiSIG.COMMENTS OWNER AUTLDER DELCANATION
<br />I hcrchy 0titn undcr pcnull, of Frrury lhd I am cxcnrpl lmm lhc O,nr,"cron Ltcn{ Ltr{ r.r rh. rolloring rc.son (Ss 701 1.5
<br />Bxsinc* rtul Pn,r.ssid C.Jc)r A.y Ciry or Counry shth rcqoncs a ltmir ro .on{rucr. alrcr, nrprovc. demolkh or replt atry
<br />srrudurc. prior h ns hsuon.c, lkorequircs rh.0F lianr for such Frmit ro filc! siSncd srarcnrnr rh heorsh. is liccnsdd tu6udr
<br />b rhe nruvision\ ofrhe Conr!.xtr s Licer*d Ljw (Chaprcr 9. ContuncinE wirh S..rion 70tro ol Division I oflhc Businc$ und
<br />Pmf.ssiors Codc) o. rh h. or sh. k cx.mpl th.Erron d rhcbaai\ rorrft all.E.d cxcnrrliotr Anyviolationolsccrio!70-ll5h,dy
<br />apllic0nl ror a pcrmir subFts thc aprliclnl lo ocivilEnrllyormr rmrcrhu. fivc hundrcd dollus(S5oo,
<br />-1.
<br />a\ o*ncr of rhc ,,Drsty. or my cmplorccs wirh soBcs N r lDr nrlc .o,nFnsrlion- will do rh. work a rhc iflriurn
<br />'xnidcndcd or ollcred tu sh (Sc-. 7014. Busim\s and Profcsn,ns Codc: Thc Cohrmbls Lhcnsc tjw docs nol opply ro rn o$ncr ol
<br />lhc pn,rcrty sho burltls or inrpr.vcr rhcMn. ald sh) des suh wort hi'n\cllor h.rsclfor rhmugh his ot hc. own cmPloyccs.
<br />polidcd rhar \urh irpmrrrcnk m ior idc L{l or oltd.i n)r slc ll ho*du, rtr huildiog or inlmrcnE h sold wirhin nnc ru
<br />of.omplcriotr,lh Owmr Buiklcr *illhaE tlr trtrilcn ol pmvin8 rhd l.c or shc dn ml tuikl or nqmrc lhc Irepcny lor rhc llrtn{ of
<br />l. rs oqNr nt rhc t olxny, !m cxclusncly conrid in8 w h liccn\cd .onrrrclor ro con(rud rnc pm itcr (Scc. 7(N-1, B!{nc$
<br />atrd lbfs\h1A)dc: ]-hc Contr.trr's Liccnso Law docs trot apply ro dn owi.r ol pn,pc(y sh) huil{h or nnpmvrs rhcr.otr.
<br />rnd *h. cotrr.lcr\ lb, strch p(,r.c( wirhxCoiknctfl\)li.cnscd ptrr\unrk, rhc Conha.kr'( t-iccn* L1w)
<br />-l
<br />r,r cxcmpr undcr Scrr
<br />Date Owner:
<br />woRl(FRac-i[]ENsATroN
<br />DDCIIAA.II!]N
<br />I hcrchy o,lnm undcr ncnllryolrc,uryone oflfic rollowinp dcclonlions:
<br />-l
<br />hrvc lrn will nEimair 0 Ccflifrc.re of Co.scnt ro Sclalnsurc lor woltcs conDcnslln'n. !s tevidcd ro. by SNl ion ST00 ol rh.
<br />tib.. Codc. fo. $c pnlormrcc ol rhc mrt lor which rhc lmil t i$ucd.
<br />/l h.vc and will nuinrain $orkc6 comrcn\{ion insurance. as rcquncd hy Ssr io lTlx) or rhc Lnbor Codc. ror Ihc pcriorromc of
<br />lnc *o h,uhth lhis Dcrmil is hecd. My*olkcrs
<br />c""t", \olc\ Rea-,b\ rc
<br />conrFnririon nrurxncc crnicr tl p.licy
<br />il ci
<br />l.cnifyrh.r inrhc p.rformnc.ofrh. work for whi.hrhis p.rfri n h{r.d.l sh0lltrot cnll.yanyp.non inony nunnc'
<br />a s ro hcconE s,hject lo lhc $o*c6 ompcnvrion hBsofCrlitomia. Md asEc rhrr ifl \hould bcco'nc stbjftr rJrlE
<br />sorkc comlc.satn'n pmvisions ot SNrio! :l7(r, ot rhc l,hor A)dc.l stull tunhsirh.onrply *irh rh.* Pmltiotrs
<br />wARNlNc l:ni[trc rJ sccurc $oricri conrpln\riflr srsrsc i\ ntrlJ{t|. r n L{'l+cr rrnr o)tr n, dinrimlpcnilricr nfd
<br />civil n,cs up lo otrc hufrkcd rhru\and do
<br />S(rio. l{)?6.lrh.lrl Cnl. inr.re{ and,"*--35-tZ
<br />^
<br />hlirio, k) rhc ron .r co rfcnlxrjo . 'nrgcr is prnvidcd n)r rhc
<br />(
<br />DECI,Af,AIA!
<br />I h.Eby dfllrE und.r p.n,l'y or pdjury thd I an liccnsd und.r povision ol chaflc 9 (conmnc ing wilh Scdi.n 7000) of Divnion -l
<br />of thc B$ircss and Pofc$ions Codc, and m, liccnsc h firll forc and cild.
<br />D C ?tt1wq-5-(B ;grua
<br />CANIIAISIOIIIEII,IINCICENIJ
<br />I h.rb, nfiinn undd lj.nrlryoft'crjuryrhar lhcrc G 0 conirucrio. bndi.8 agcncy tu rhc !.duromc ofrhe work for shich rhk Pn'nir i\
<br />hsucd (sr :1097. ci!. c.).
<br />AITIICANLDECI,ASAI&!
<br />I h@ti, alim udcr pcnalry of pcrju,y orc or rhc rollowing drlrar iooq:
<br />Dcmliliotr Pcn ls.Asbc(os Nolificalion Fedcrol Rcsulations (mt 40, Parr6)
<br />-Requircd
<br />brterof Notifi arion
<br />I.cdilirhar rh. redcrrlr.guhrn,N rc8rding ,\b.tros rcmr trl lrc nor dppli.ahl. ro rhii flojftr.
<br />lLl.cn yrhrIhrvcrcr'lrh'.annl'cJrtr'nJJit{rcrhir,heah)vci'raornd n is .om.l. I .!rN lo conDly w irh r,l Ciry rid Cou y
<br />urdi.r.c! iJ Srrr.liws rl:llin! h rcnrcsctrr.tivcs olrhh Ciry and C.lnrytu e er
<br />3h.v. nrfrnnrcd Pmt^-n)] nr i,r Ll
<br />Aplli(unl or AScnl Si8n!lrr€-5-
<br />S6ICq
<br />";u;
<br />ts?<e
<br />e 16
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Lite Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondinq / Groundino i UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Condilioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilinqs (T-Bar Rouoh)
<br />[/eter Release /,1// //( E 1t1rx4 t 'l-
<br />Rouqh
<br />Service It/eter o//hr'. E ?Mr h-
<br />FINAL ri//i/r*-i V/46-7r+/6'2-
<br />Notes, Remarks, Etc 7-- /-
<br />,,1
<br />DATE
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