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ELECTRICAL-INSPECTOR BECORD
<br />APPROVALS DATE ID/SIG.OWNI'R BUILDEN DDLC RATION
<br />I hcrcby rriirn undcr p.nrllyol|trrjury rhrl I cxcnrrl fron lhc C. ructns Lic.n\c Itrs to.llr rblloNins Ervr llsc.7O.1l I
<br />Busirrcs nuj Pmlc$ion C{nlc): Any Ciry or Coxnrt which rcqun s r l).mlil io con(ocr. allcr, i.ryrovc. dcmli\h or rcpdt dny
<br />dtucrurc. l)rntr nr ir\ i*uncc. trho rcqunc( $c amli.rnr ior such p.nnn ro ilc e sisncd (atcmnr rhtrr h.or \hc t liccnscd nu uanr,
<br />Io ihc pmvnions oi rhc Coalmctofs l-iansed ljs (Charrer 9. Comtuncine wirh S..rion 7000 of Division :l oa rh. Brsincs nnd
<br />Ptr'acsion\ Code ) or rn hcor\hcicxc:nnrrhcrcfiumadrhrbr\i\nrihrrllc8cdcrcnDlion An,li,,larionotS.cri,tr7011.5hyeny
<br />rmli.r li,r a r.nnir sxhj(rs lh. appli.{trr lo rcivilpcnrhyolnot nmrclhnn livc hhdrcd dollln ($5(xr)
<br />-l.rs
<br />oqncr ol lhc proFny. {tr
<br />'r
<br />cfrPbycdr wirh srrts ^ rhcn $lI .onlEns ion. silldo rlt Eo* lnd rhc {dm i\ d
<br />nncndcd o. ontrcd lbr qL (S( 7(Y4. Busincs rnd Prolt$iotr. Coil. rhc C.ntrlcroi\ I"i.=n\c liw do.\ nol (prly r' m ow.ct oi
<br />thc pmn dy * ho huilds .r inrl,r.yc rher6n. ald wlxl dm\ such $o* hnnrlf or hcr$lf or rhmugh his or h.r .wn .nPn,yccs.
<br />pmvid.d rhrr such irnpmvcmnrs tuc tror ir cndd .r oltisl lor $k. li lx,*ctr, rh. hikl irg or nntmvcnEnt h s,H within on. F
<br />ofconlnbrion- rhc Osm' BdiU.r willh.w rh. hdd,cn ofroving rlrtr h. or shc dil mr buikl o. tlll'm@ rtu tn,tdy for lhc l)lqrN oi
<br />Lasosmrotrhcpmp.nr.!mcrclusivclyconlm.li.swnnliccnsedconrract,sb..nnMrrh.PR,/:cl(SN.7lll4-lJt\inrs
<br />lnd hnlL.si,n Codc: Thc Conlructr\ Liccnsc Law docs nor at,plyt, Mowncr olpropcny who huild\ or impi.v.s rhcrcon.
<br />and who conrr.r\ r.i su.h rbF.ls wilh a Co mcto(t liccn{cd pur\lllll nr rhc Cinnracttr s Li.ctrr Law)
<br />l: rxcn'Dt unJcrsc.'rbn .ts &PC lnrlhi.'.,r',n
<br />Del. OBner:
<br />w()RI(r'Rs' coMiEilsAlloli
<br />IIESJAA.IIIIN
<br />I hcrchrannrundcr FnrlryorrrluryoNof lhcfollowinSdc.horions:
<br />-l
<br />harc 0.d wiu nuinhin ! C.nitkarc or con\cnr ro scll.ln\urc fn workcN competr$rnnr, sr S,vidtd ror by Sslion 37(U oI rtf,
<br />L{hor Codc. for th. ncrfornume ol rhc w.rk for whi.h rhc n mir i! i\\urd.
<br />lhrvrrndwillnririn$orkcri.onrNnsarioninsur0nce-asicquircdhyS..rn,nlT(X).lrhcLlbotCodc.lorlhcpcrlomtrccor
<br />rhc sork for whi.hrhis pcrmit is hsucn. Mywo*c6 conrpcnsarn,n in\urrtuc .Micnnl !.li.y nun$c, nrc:
<br />qatb(d ,,.i $lz-lrq
<br />-l
<br />ccniay rhd in rhc pcri.r@n.. orrh. work ror whah rhis tri.nn n hsu.d- I sh,ll nol etplo, any n K,n in.ny matrrcr
<br />s *totr.om subrc.r ro r lrc woricc .omrens ionl.qsofcaliforni!. and,gNrhd ill should t.oE suhjccrb rh8
<br />sorkcs'.omncnsrrio.provisiotrsofSdi.nlT(rollhcLitnrCode.l\hrll,nnhwi'h.onrPlywilhihosrn'vhion\
<br />WA|{NIN(;: hihtrc lo v.urc *or(cn .onFnsdn .ovcralc i\ unlnqtul. n shtrll suhje.r an enrpbr.i ro ri,niMl lEtrrhis md
<br />civil fincs up ro orc hundrcd rhou\dnd d.llrl(!l0o.mo). n rddfion t. rhc.osl.f.onpcn drm8cs !s providcd lq rnc
<br />sc.ri, r 1076 or rlt l.ib(, (itrlc. i,icrcn
<br />t)r( l \Rlt rrf,.'
<br />I h.d)y rlrirn undn Ftr.lryofpc4ury thrl I {m liccn{n under pn,vision o{ch,frcr 9(.onrmncins wilh Ssrion 7(Ix) orDivision l
<br />o, rhc Bu\ines und hor.s\ions codc. dd my lic.nrc is ir lull lnrce aln cirg,r
<br />l llllri ll o
<br />zuli<
<br />SAIIIBI]I:IIANIENDINIi.{GENII
<br />I hcnb, lmim undcr F6,lty of p.dury lhol rhcrc h a onnndion lcndi.s lscfty ror rhc ,,afolruRc of lhe *orl for whhh rhis !..nir ic
<br />ksucd (S< 1097. Civ. C.).
<br />APPt ICANT DECLARAT!ON
<br />I tinhy aninn undcr pcnah y or p(rjury oR of rhc rollowinS dRlrtrl ions
<br />Dcmoliriotr Pcrmih Asbesr.s N.rifi.rrion Fcd.rrl R.gulnlions (Tillc40, P.n6)
<br />-Rcqutcd
<br />Ldrcr ol Norifrari0'
<br />I .dity rhar rhc rcdcBl rc8llarions reBnding lsbc(os rcmvrl rc .or arrrli.dbk ro lhis pmjL\1.
<br />u-
<br />t1l enrfyrhd I htr\c rcld rhnonplkdinnund dar hJr rh. nhive inr.rmlion h corccl I osle lo comPly wnh a:l Cil, {nd C.unly
<br />odimfrcs.nd sr.rc Laws rclirin8 I I ix rcDresc 0tivcs oflhis City lnd Coudyio.nrc! unotr rh.
<br />Jlxro nrnrnnrd frt)nc y f(tr i
<br />,\ppli.o orAA€tr1Si8nrl
<br />r)\Itl\l atc llTrtf l^-{lrolll
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Satety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Solfit Rouoh
<br />Ceilinqs (T-Bar Rouqh)
<br />[/eter Release
<br />Rouoh 1/'l/ls 5^{{n
<br />FINAL 7/rt/ts ,)61
<br />Notes, Remarks, Etc
<br />COMMENTS
<br />Service [/eter
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