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ELECTRICAL-INSPECTOR BECORD
<br />APPHOVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATTON
<br />I hcrcb, !finm undcr pcnalry oI !.rjury lhd I m cx.mpl rmn rhc Conra.b( Li.uns bw ror th. rollouing rc{sn (s.c.7oll 5
<br />Busin.$ nnd Pofc*ion Codc): Any Ciry or County which rcqutcs 0 rEflnil ro Nnsrrucl. ah.r, improvr, d.mlish or EIv My
<br />slrucrurc, trirr lo ns issum.. also rcquncs rh.applka {.r such Fnnit ro filc a sisncd slutcmnt thlthcorsk is licensd puNrnt
<br />lo thc pmvirn,ns oI lhc Conr,Erors l,iccn*d lj! (Chaptcr 9. CommcEitrs wilh Sccriotr 7uD of Division 3 ofth. Businc$ 0nd
<br />PDltsrions Codc)or thar rE or sh. ia cxc,nl)r th.rcfrunsnd the bash lor rhc lllescd cicmrrion Anyriolarionolsecrion 70.)1.5 hyon,
<br />,rplicunr fo! a Fnnil subjdslhc aptlic!trrto r.ivilpcmhyofnor nbrcrha.fivc hundrcd dollai!($500).
<br />_1. $ owRr of rhc p(rlf,nt, or n1y .ilplo,ter wirh MEcs (\ thcn mb compcnsa! ior. *ill do rhc *uk md lhc srtocr@ i\ d'r
<br />inrcBLn or oifcrcd l'or $lc (Sa.'7(}44. Busim$ md Pr.f.sions Codc Th. Contucror's Li..ni. tjw do.s nor applyro an owftr.f
<br />lhc pmp.(y vho buildeor inpbvc\ rhcE n. ud who da\ such wo,t hitrNclfo, hercllor rhroush his or hqown enuloyccs.
<br />Pmlidcd ther soch imtovcrnh 4c nn iorcndcd orolIund furslc.lf. hoscki rhc hoiklii8 or inqx,vcmnr is lold withinoic rrrofdmlhrir- rhc Owner ltuillcr will harc lhc burdcn oapmvin8 thjr hc or shc dil n.r huild or i'qrorc thc ln,Fnt fu rth nuqxRol
<br />l. rrosierolrhcoopeny. omc{clurilel}.onhclin8 ailh licctr*d.onrr 106 ro conndd rrE t,oid (Scc 7N4. Burms
<br />.nd PlDfsstun codcr Thc conta.roi s Liccns.l-as do.s nor lrply ro 0n o*nq olrropcnywho huilds or imnmvcs rhcrcon.
<br />hd sho conrr.crs lor such projccts wirh a Conrm.ton9 lkcn*d px(u rturh.conr,.k tLkcnscLrw).
<br />I lncxcn rndcrSsrt'n-. B & P.C. forrhisrcov,n
<br />Dste. Orncr
<br />woR(ER'$ C( lllPE,^I.\aTl(),\
<br />DDII.AXAII!]N
<br />I hscby amrm undcr p€nalry ol pcdury ore ollhc lollowin8 deld0rions
<br />I hrlc ad*ill mainlain !CenificalcofConscnt ro Scll-lnsurcror wor*cm comJ'cnsonon. us pmvAcd nxbySL{lion 3r(x)oflhc
<br />L8txtr Codc, aor lhc pc!{o.nurc of lne wo.k for which rhc r.mn n h{cd.
<br />-lhrvc!trdwill kn r[ForkcNc n{c lrrbn surrncc. r\ rcquircdhyScdi{n,]7{X)ofrheL$orCodc,lorrhcp.rfonna.ccof
<br />rh. *ork lnr $hich rhis lrnnir is is\ud Mysorkcs .otr,pctr\arnn, in\uan(crnicr xl plicynr ,tr. rr:
<br />c,.r.. . sla+P liane Ci)
<br />q 2z-\cioa t2 l?f ltd
<br />-l
<br />ccniryrhdt in lhcl..la Dn..ofrhcworkturwhictlhi\pcnlil(hsucd-|shollnorc"Uloroypcr\oninatry'nurmr
<br />$ asl. h.conE suhid lo thc *orkcn compctrsrLotr l.ws oaCalitnmii. nfd igr.c rh.r ifl sh.uld hcomc suhlcr ro rh
<br />workcr' .om!.nsrlion pmvhions nf Scclion l7m of rhc btrr Cdlr, I \lhll. lonhwirh .onllrly wnh rhos phvisions..
<br />WARNINC Firilurc lo surc workc,l contpcn{n,n .ovoigc is unldwtul. d sh,ll cubjel ,n .m,iloyn b aininrl ,.nrlliN n
<br />.ivil fincs uplooE hundrcd lhousand dollus ($lm.00o). in.ddirion h lhc.osr .f.omp(nrdbtr drmScs as nrovidcd for rh.
<br />sc(rtrnr :1076.r rho l jb(ncoll.. i, .rn an Jronf,r'\ li.\
<br />_-t-oa", ' I l2L Appliorr: E
<br />DIIIAAAIION
<br />I hcrchy nlltn uM$ nc.rlry ol prrJury rhd I ah lic. Bl undcr pnNhiur ol Chrnrcr 9 l con,B!. in! sirh SLrriD 7( 0 ) of Dirilion .l
<br />of rlca \ines md Prcfcsion\Codc, nd nrvliccn\c n ir lull lorcc oMcl'licr
<br />i1 .nsc.,unrrr:r:' /O34i5\
<br />3l ]b ltt
<br />CONSIBI]qII9IIEN}INC.ACIIII
<br />I hcEby ortrn undcr Fnrhyof pcrjury lnd
<br />'h.rc
<br />is !.lNrru.lirn Lndingr8cRr lor rh. p.rlolr1mc orrh. sork for qhi.h
<br />'hh Fmir k
<br />ksucn (Scc.3097. Civ. C.)
<br />AEELISAILDEII/TAIIO!
<br />I M,y aliim utrd.r l)cnoll y ol Frjury o.c ol lhc follosin! d..luarnrns:
<br />D.m ion P.roits Asb.{oc Norincari.n Fcdeftl Resllariotrs (Tirlc40. Pan6)
<br />Rcqxircd L.trq ol Noril@liro
<br />-l
<br />ccnify rhat lhc f€dcml rcBul,tions E8ffdine ahcsbs ftmvrl e mr rppltabk ro thi! pmiH.
<br />DgI .diry rhar I havc Ead rhn applicarn n ad shrc lhal rhc aboEnromr ion is coret. I a8.e ro .om ywirhlllciryandcounry
<br />ordimnes and srar. trs. rhii.g ro bualding .onsrrudion- ed hcrcby aortnriz rcltrcsnt rivcs of rhis Ciry and Couiry ro enrcr upon rh€
<br />rh'vc mnunrcd frcFcny lor insl]€dhn Nrrnrcs ,-------)
<br />^rot;*ro, nr-rsr**'un l ---,= -l-711 *r" ' Rlcrtir-
<br />*.-,.-*rp^*l K frikl Q-Sh€tlar"i
<br />Site-Work
<br />Under ground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Firq Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Bonding / Groundinq / UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Solfit Rouoh
<br />Ceilings (T-Bar Rough)
<br />Meter Release
<br />Rou gh 1 (l(G "^"/v,/.LtllService lvleter Dt \2
<br />FINAL 1 :?\
<br />Notes, Remarks , EtC.I ul
<br />.-:D
<br />Under Slab / Floor
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