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ELEGTRICAL.INSPECTOR RECORD <br />APPROVALS ID/SIG.COMMENTS Ownr-Build- Daletio. <br />I hcrcby .mm undd p.r!lt, of pajury ihr I e .rmpr tm ['c C@t ctoR Licos. (lw fd tn. followin8 Ga@ (!*.1031 .5 Bui.st <br />Md Proi6ion Cod.): An, City or C.uty which Equn6 a pdmit lo onslrld, .ltd, imFDvc, drmoli5h o. rclst y th.rG, Fior to iE <br />isruec., aho r.qune lh. appli@t for such pcmi b fil. a si8n.d slaldml lhr,l hc or lhc i! licn3cd puuuut io L\. prDviri@s ol lhc <br />Coirerois Licaed L.w (Cn.pt!r 9, C@madnS wit S.cdon 7000 ol Division I of.h. Buiner ud Pbfdiois Codc) or thll h. m <br />rh. is cx.mfl $.efroh ud lnc bai! fd $. all.gcd aoprio An, viol.do. ol Sdtion 703 I 5 by dy aprlic&r lor i Fnir subj.cE rh! <br />applicdt ro i civilpaalty ofnor m@|lta nvc hlidrcd dolla {1500) <br />_1, s oma of thc ptupqty, d my dploycG *iln uas6 6 lhcn solc compcnsdion, vill do ih. wsk d th. slru.rur i! not intmdcd <br />or ofid.d fe 3.1. ( Scc.70a4, Bui.6r od Pof6sids Cod., Tlq Cohr@ror's Li.ar. La* d@s not .pply lo e sncr of 6c prop.ny <br />who buildr or imprcve thqr.on, sd who do.s such wok himlclfor h6.lf or $rcu8h his or h.ro*n mploy..!, providcd tlar ruch <br />imprcv.m..E e nor inknd.d or offs.d fo salc If, h@.vs, rhc buildiig or inprovdcit k soE *nhin onc yd ol cohpl.!@, thc <br />Owrr-Buil'lq w,ll hav. lh. burd.n ol proving thd h. tr sh. not build or inprcv. fc rh. purpos. of sal.) <br />_1, 6 ow.cr ol th. prop.ny. o .xclusiEly conEicting vith lic.ns.d cotrracrm lo const uct rhc prcjccl ( 56 7044, a6in* 6d <br />Pbfeion Cod.: Th. Co.r&rtr 3 Li6s. L.w 1106 Dor apply ro d oqq of prcpqry who build! d inpove rla.6 , ed vno <br />conrBc$ for such prcj.ds *iih . contreto(') lic.ns.d puBumr ro rhc co.k.crofi Liccis tiw ) <br />_l m cxdpt urdd Scclio._,8.&PC fd this rcaon <br />WORKERS COMPENSATION DECLARATION <br />I hcrcby atiim und.rpcnalty oi pajury onc ofth. aollowinB del,ations: <br />_l h3v. dd pill m.intdn r C.ni6.ar. of Cms.nt to S.lflns@ for vdk6 cmF r.tion, s provid.d fd by Sedor lTOo ol ln. <br />Lrboi Codc, for thc pdforr@e ol fi. wo* for which thc pcmil is i$u.d <br />_l havc od will mainraii sdtcR compcnsation insumcc, a rcquird by Scction 3700 oafic l-3bor Cod.,lu th. pqlomec. ofth. <br />work for *hich this pdmn h issucd My *orlcE' @mp.Etion inruank csi.r a'l policy numb.r @ <br />PolicyNumb.r: ExriB <br />dil;#ffiffi;fo, Oic hlndr.d dotlm Itl00) orle) <br />orovtrio ol S.crid J70O-8- r> I olth. Ldor Cod., I rhall, fonhuitt7 <br />*n(ffi failur. ro !du,c *ort6' @mp.ns.don cov.rag. il <br />6n6 up to on. nun<,rcd thoulad doUE (lloo.om),ir 3ddidon b <br />rhc Labor Cod., int 16r &d sltoh.yt f6. <br />s provi&d for 0r? S.cli@ 10?6 ol <br />I hfcby affim undd p.tulty ol p.qury thlt I m licat?d undd prcviiion of Ch.pr.r 9 <br />$. Budnased Prof6sions Codq ud my licoic is i. aullaorc dd eff.cr <br />I h@by.fiim uodapollty ollnjury $!t ac i! r @istrucrioD <br />i$ucd (Sm.109?, Civ. C.). <br />olrhc work for whrch tht pcmtr is <br />APILICANrTS DECI,ARATTON <br />Ddolirion ?mils-A5b6tG NotifietioD r.d@l R.sollrids (Tirt. 40, Pdl 6) <br />_ Rcqutcd LGna ofNo fic.d@ <br />I a8rc rocmplyvnh lllCiryMd Cou.ty <br />vd oflhis City .nd County to <br />abov. ncndoncd p6p.ny for i p.clion o '0 <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Transformers <br />Torquing <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soffit Rough <br />Ceilings (T-Bar Rough) <br />Meter Release <br />Exp IFlFN <br />Rough <br />Service Meter FEB O I 20t9 <br />FINAL <br />Notes, Remarks, Etc - -.-vo; rJo, 6i6-r <br />DATE <br />Sub-Panels <br />f------T------ <br />tl