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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS ID/SIG.COMMENTS OWNER BUILDER DEL(ARATION <br />I hdclir amm und6 po.hy of prjury lhal I m .x.mp tuh tbc Co r.to6 l-icoe llw lor lhc follopins r.en (Sa 703 I 5 <br />Buiinc anl Profdion Cod.): Any City or Counl, $hi.h r.qut6 . pann to co.stucl, alld. inrrov.. danolish or rqEn dy <br />slrudu.. Fior ro nr isudcc, 6Lro r.quiG rhc a,plicol tor such Fflni to 61. s si8..d slatftd rhd lE or lhc b licft.d l,o&mr <br />ro lh. pmvnio6 olr& Contrrcroi3 Lic.trFd L.s (Cfi.prd 9, comdcins $ilh s..rio. 7000 oaDivnio.I offi. acr* sd <br />Polsions Codc) or rhsl h. or sh. is .r.mpi rhdcfton &d thc bsis for thc rllcscd etdption. Any violalion olscclhn 7011.5 by any <br />.ppli.a for a pcmn subjcts rhc applicanrloscivilp.mlrtolnorftorerhmnr.hundr.ndo0s(ttoo) <br />l. 6 ownd oath. FoFnr. or my .mtlo)6 wnh ur6 6 lh.t elc comp.nsation. s ill do th. \ort ud lhc stnIlu. G not <br />inldxj€d or or6.d for sal. (56 7044. Buli.d ed Psf*io.s Codc 11. Contr&1ois l,iccN L,w &6 mt apply to u orM of <br />rhc pllFr, who hril& or iiFor6 thd@q d vho &6 such M* hims.lf or hGclfor rhrclBh his or h6 oM mployce <br />prcviLd rhal such inFowls m mt i.nod.d n olI6.d lor el. If. ho{6 d. rh. hildin{ or inprov@r aq $ld *nh'n on. ya <br />olcompkiotr lh. O*M BuiU- wil b.v. fi. hfd@ of Fovins lhd hc or shc d'd mt build or mFovc lh€ propory for rhc purro$ of <br />I, a omd olthc Fopcly. d qclsivcly .onlracri.8 snh Lcar.d .ontrcrou lo coKrud th. projd (Sc. 7044. B6in6 <br />ud PFftsrinCod.: Th. Co.trrcro.s Licdi. Law d.6 not applylo oM6 ofp.opaly who buildio, imprcv6th6@n. <br />md who .onrB.ls for such prcjels wilh . Conlralo(s) licaE d pmmr t. rh. Codracioa3 Lic@ rlw) <br />I m cxcnpr undo Sdrion <br />o*n6: <br />nqaKEB!:caurursaro!utcl,A!Al[]! <br />I hs.by oifirm x.de pdah, olFjry on. olrhc rolbwing d(ldal ions: <br />I hre. ad *ill n.inr.i. . Cdrificrr. of CoMr ro S.lf-lEur. for workd comF$Iion. s Fovid.d fo. by SRlion 1700 oarn <br />l-bor Cod., for lbc Fforl@c o I $. volt for which lh. p6trn b isu.n <br />a hN. .rd wrll mrinhin "r 6 compftdri.n itumncc, s rcquiEd by S(non I7OO olth. ltbor Codc. lor lh. ,dloftdc€ of <br />lh. work lor which thie p6nil is is{.d. My wort6 comDaa{ioo i6urs.. 6i6 ard Flicy numbq el <br />Q'rL,-5 <br />Jtt -'12i3$2G'l -/1,,,,",(?/7tft2 <br />I cdl,rylhal in lh. pslolmncc oflh€ *ork aor which lhis Fr6n is ilsucd.l shill not mploy ey tE$. in ey ndnd <br />e s <br />'o <br />b.(om..ubjd ro thc *ort6' coftpoBario. la{s of Cdlifomh. od asrfr thar ifl $ould b.com. subjcr to llE <br />uorld' compdstion pmvGioB of Sdion l70O oath. l*or Cod.. I slEll. fonhs'Ilh comply wilh thos rorisrG <br />WARNINC: Failu,c lo s.q€ *0116 mmp$aliof, cov6rg. is unlasful. md shall subjd dp,oF ro riminal Fn.lli6 ed <br />cilil [n6 up ro onc hundr.d lhoend doll6 (5100.000). in addirio. ro th. ccr of con!.Mtiod. d.rug.s I prorid.n for rhc <br />Lahr Codc imGr ed ,noma \ f6 <br />DECI,Af,AIIA! <br />I hicby .Ifm @dd pcnalty ol pdjury lhal I m lic.Ncd mdq FDvilion of clBplo 9 (omo.iig sith S6rirn 7000) of Division l <br />of tn AGbd dd Prbf6ioB Cod.. ad ny li..@ i! in lul rore d{t clfcr <br />COISIBUCIPNIENDINC-AGENCI <br />I heby rrrm md6 p.nahy o f pqju,r_ rhd rh6. n ! onntudion Lndins asacy lor lhc psfomuc. of th. {o,k for *ti.h rhn p6nn b <br />isstr.d (5( :1097, Civ C.) <br />affuc NLpEct ASar.lg! <br />I ha$y rltm u.dr pdaly ol pdjury onc ol rhc followinA dcltrar ions: <br />D.nolilion PdmiteAsb6tos Nolificalion f.ddal R.gulorions (Tnl. 40, Pd6) <br />R.qur€d Lclrr of Nolifi stion <br />I cdii, rhd rh. fdid,l r.sularioG eadrdi.g Nb6tos rmovalE. nol lpplicablc ro this pmjcd <br />I cglrly rhar I hav.,.ad Ihis applicarion dd st .rhai rh. abv. ,nrom,lie. 6 cor(l I !!rdlo conplys'rh all C y rnd Coum} <br />ordrdc6 ud Slal. Laws Elariry ro hiildiu codrucrion ad hd.6, ru$oriz EFsardiv6 of <br />H:.ffij/'#f E.-sh <br />d lL /tE <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />S pas, Pool, Fountains <br />Si NS monument A <br />Y -'l't7 X]r:$L I <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Building <br />Under Slab / Floor <br />Bondin / Groundin / UFER V-1't7 >.1{-)t;.) <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soffit Rough <br />/,) <br />Meter Release N-to-)7 ,-v.ab <br />IJ <br />Rough <br />Service Meter K-1-t7 \"v-ua{-1-i7 a.tafl <br />Notes, Remarks, Etc.av <br />DATE <br />YE/4.f roup,L l5(fl <br />Communications Cable <br />Roof Top Equipment <br />Ceilinqs (T-Bar Rouqh) <br />FINAL <br />It &P( f.r rhir r.i$nr