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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.OWNER BU!LDEN DELCARATION
<br />I h.rht arinm lndcr pctulrr of rErjury rh l am excnDl fiom rhc Conrraclon l-icense llw lor lhe followirs m$n (Scc 70.115
<br />Busincsr arr Pn,icsrnr C,rlc): Any Cn, or Cnhry which .cquircs r pcmii b consrocr. ulrcr. imlrov€. dcmr(h ,tr mrJn ony
<br />\rru.tud. prior b ns isaurn... aho turlutcr thc amlica lnr suchpermirro tilc r sigftdsr c@nr rhd h.or\h. G |i..tr$d purunnr
<br />h lhc pmvGions ol tlE Contractols Liccnscd L.w lcMprcr 9. Connrncn'B qirh Sslion ?rx)o ol Oivki,n I oflhc Busincss and
<br />Pn'f.*i,,nr Codc) or rhrr h. or sh. ir cr.mpr rh.r.rrum md rh. hosis ftr rh. Elk86d .r.nprn)n. Ant viol.rion.fS..r.n703l.5 hy rny
<br />aprlicunl lhr aDcrnrir subJcch rhc orpli.aor lo acivilpcnlllyoi.ot mrclhotr nlc hundrcddolla( (5500)
<br />-1.
<br />rs owncr ol lhc pmreny. or nry cnrp,oyas wnh wa8.s N rh.tr vnc onpcnsrtiotr. will do lhc wort dd lhc slB-lurc h not
<br />intenilcd or otttred f{r $,c lSa.7O44. BusiRs and Prcltsions Codc Thc Cotrtrrctols Li.cnsc Llw docs ml npply lo an o*rcrof
<br />rhd pmlrny wbt ikts or ir'llroEs rt*ru,n. rJd *ho dffi smi *orl hinrcll or hc*dlf oi rhmueh hh or h.i ow..mployes.
<br />0rovidcd rhar such impmrcrrnh m mr inlc.r& or ofi!rcd lor {h. It horrwr. l,lc boilding or iq,mkftnr ir mkl *irhin otu }tar
<br />ofconflctio..rncosrcrBu dnwiutuEth.bhlcnofpmvingfidtEo.shcdildhoilloriflI,nNthcpDpcnytulh.r,Fsof
<br />l. r\orncrollhc roFny. nc:rlNilclyconlrrcrir8wirhlftnscd.ornx.tnt,mn(tu.rrhrrxiccr(s( 7l!4, Btr\i'trt\
<br />itrd Lhlsshtr Codc lhc Cont..r.as l-i.ctrsc Law dcs tr.r rmlyro in owncr ot fo|xny n h. builds or inrDrovc\ rhcrcon.
<br />an'l *ho onirrcrs i,tr such pm,ccr $irh r(onrEcb(s) liccnscd puruint t,rh.Conrrtr'\ Liccn\c Lra)
<br />-!!
<br />.iemprundcrSslion-. B &PC forlhhrco$n
<br />Dole: Ormr:
<br />W( IRKFRS' C(NTPE\SATON
<br />DECI.Af,AtrON
<br />I h.r.by rt1]rftund.r JEnalryotBrjury on..frhc rolbwinp dNl alb.il
<br />Ihnw rd will mdnlrin a Ccnifi.ric or Conscnl b Sclf.lnsur ir work.tr c.mpctrslion. as pmvidcd for by Sdnnr ]700 o, rhc
<br />Ltrb.r Cod..lirr rhc Frlbrnrdn.c ofrhr wof* fd which thc pcdir i\ isNd.
<br />Md e ill 'niinrah sorkcr' comncivrnrn in\urrN.. r\ rc{luncd h, Sc.r i,)n l7U} of rhe lrh.r A)d., for rhc trfomuftc of
<br />fffwhi.hrhi\ pcrnir n t\u.i Mysorkcrr conpcn\rlt,n in\rrancc c! cr a*l Brl(y nun$n d.
<br />t v,tP S&vc (ar"uP
<br />Pila -t UZqo?l-!F I
<br />-l
<br />ccrlilirhfl inlhc !.rfoirmn..olthc work ror whi.hrhis p.,rnn is iisudl,I sh.ll not cnl!'loyanyl}c^otr in anymonmt
<br />v, s ro hccom srl,Jc.l lo lhc soirqi comrE.s.rion lNs of Cllifomio. and o8rc rhll il I sln,uld hec.m subjccr ro rtr
<br />ko![c6' ompentl ion pnlnions of Sccrion ]?00 of rhc ljbor Codc. I shall. rbnhvirh Nmpl, *irh rhxe polniont
<br />WARNINC: Fdiluru n) {.ur. sorkc^ c. rpcnsarnx.a,vrralc ir unh{lul. rnd shall suhjc.r dr c ll)loycr r. aiminil lttrrhic\ rnd
<br />i) oN hr drcd rh.u\Jnd dollrr\ rSllX)(XX)) i', rdJiri,r ro rhl .o{ of ..tr )p.n\ario.. damgcs 3s providcd for rh.
<br />,.:'l?lEtrii ".'^
<br />DECl,dEAuA!
<br />I h.rbt.fiirm uMcr Fn0hyolp.rjury rhd I rm lioflrd und Fovijon ol Clrptc. 9 (mmnrmin8 with Sdion ?OO0) oa Divnion .l
<br />of rhc Blriturs artd Pmrcssn,ns Codc, aJkl n,y licc.r is in full f{ne and.fli.r
<br />t,"^""rt", bf c34 r:-ooS3'e[! 1s
<br />taMirf,lJcuoNj !!DlNti-&cD!c.r
<br />I hctuhyrflir ruidcrF rkyorp.ijuryrlx rhcrcis!.o {ocri L di'rE rgcicy rrtr thc poranrnNc of rhc work for *hich thn [l.rnil h
<br />issucd (Scc.3097.Civ. C ).
<br />A.Tzu!^iA!I.DECI,TBAIION
<br />I hs$ryammundcr !.n ty ol prju.y orc of lh. follo*in8 delml ions
<br />D.rmlirion P.rnir s Ac bcaros Noti 6c 0r ion Fcd.ral R.guLtion\ tTnb 40. Pd6)
<br />-RcquiR.d
<br />t ll.rof Norificalion
<br />-l
<br />ccrlili thar lnc lcdcrd rc8uhtiotrs Esrdins asbcnos rcn$vllarc nor lpplicuhlc t, ihis nDjsr
<br />l.cdifyrhd I hivc mrd rht applicrri.n rnl sr. rh r rh.rh,vc infun i.n n .otrLrr. l .gtu ro .onl['ly uirh 0ll Cny aod Coutrly
<br />ordindn.cs nnd slrc lf,ws dbring ro huildinS con{tucrnrn.,rl h$chy aurktriz. rcEc*nrarivcs olrhis cnylnd counry ro cnrcr upon rhc
<br />rhrr Df, nriinrn pmn.ny nx i,rt.criorxAppliutrt or Agctrt SiAn{tur.
<br />*".rU." uunr",Onu,,, K *',.<A;4.-r^.r,-
<br />.6/sftb
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltaqe
<br />Fi re Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondin g/Grounding/UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Rool To p Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Bouqh)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />Rough
<br />Service lvleter
<br />FINAL 3ts-te .-/)cJy,{y")
<br />Notes, Remarks, Etc.
<br />COMMENTS
<br />tlr dri. Addc\.
<br />Meter Release
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