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ELECTRICAL.INSPECTOR RECOHD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUN-DER DELCAR TION
<br />I hcrcby afirm undcr Ftroxy of pcrjury lhal I aD cxcnpl liom thc Conr,adoF Li.cn{ ljw ro. lh! followi4 rcN,n (S\-' ?o.t l 5
<br />ausin.s .nd Prolision Codc)r Any Ciry or Colnry which GqliEs n Fnnir ro .onnrucr, altcr, imp,ot. dcmlkh or rcI'0n any
<br />srrucrurc. rrhrh ns issuancc. al$ r.qutB rhc,rn!i.dr ror su.h Fnnil lo lilc a sisncd rlllcmnl rhtr lfoi shc is licctr*d Puruanl
<br />x' rhc 0oviions ol thc Contfrclols Liccnscd t w (Ch.plcr 9. CoD.rn.inA wirh Sccrior 7000 of Division 3 ofrhc susncss aDd
<br />PnrlcsionsCodc)orlhlrhco6hch.x.nDrlh.r.rromandrhcbasislorrhcalksedcxcnprnn.Anyvn,hrionolSR-lion'703l5l,yeny
<br />aptli.a r.r s pcrnir sublcch rhc amlicani lo !cililpcnalltolnot morclhoi lile hunildd dollrs (Ssujl.
<br />-1.
<br />n ovtrcr ol'rhc proDcnr, (r my conl.Fcs *irh sases u\ rhct s,lc .omrctr\(n,n. uill do thc suk ,'t rh. qrmrurc i Rn
<br />inrcnd.d or orercd fr slc (S( 70rl. Businc$ md Pft,fcsion Codc Thc aonlacror's Litnsc hw docs nor aPply ln an o*t. of
<br />lhcDmruly qI[ huilds or nnnovcs rhcrG'n, trfrl eho docs sdch w(, hnnsclrorhcrcllorlhnushhisorhcrowncmrloyccs.
<br />prcvidcd ihnr5uch nnlmhrrnr\.ErF ir cndcd oroflaEt L, \..Il howcvcr rhc l,uiklinp orinDmt' m is qikl wiihin nc rrrr
<br />ofconrrlcri,n. rhcOs.cr AuiLld wil hrvc rlE blrdctr oftrulinS rhd hc or shc did norhild or i'nEovt rh. fmr.dy tbr ltr puqDs of
<br />I. !s own.rorrM tmtMy, ancxcl$ivclyco ractins with li.en\cd conrra.i)n ro (rsrdct ttE l)mrcr (Scc 7Or4. Bue..$
<br />ird tbfc$hn CodD ThcConrractn s l-ic.nsc l-,w d.cs n.r arplth.nowmrof[o!cnyvho huildsdr imttuvcs Ihcreon.
<br />rid who.onrmrsforsuchFmj.rtswirhaconrBcbnnlicenscdlrusus 6rh.conta.roisLiEnscL!*)
<br />I ancrcnr undcr Scclio
<br />ItaB$&5:r9lltINSArlQN
<br />DLC].d36IION
<br />I hcrcby !finn undcr pcnrhyorp..jury on. orrhc roll.win8 dcclaorion\l
<br />-l
<br />havc aid sill minrnin . Ccnific0ic of Conscnt hSclaInsuEi wortcd Nmp.nuion. as ,mva.d for ny S(li)n l70o .f thc
<br />Lihor Codc. for ltc pertormnft or rhc wort ror whi.h lhc ,cmiit is tsrrd.
<br />I hrv..nd will nuinhir workcrl c.nDens(lion insulimc- !\ rcqutcd byS*rion:l7Lx).tthc Lrbor Codc, nnrhd p.{or Nn.c of
<br />I [tr{lrLrl'r'ri r i. i\{'rJ Nl\ uurlrh'fil.lo+'t- c/^i\
<br />co'nfctrsriion insur,mccarid 0ft1lolicynumbcr e
<br />1.16.
<br />rNvurcoo?d>e'r.\.
<br />-l
<br />.cn ify lhlr io ihc pcrfo,tun.. or rhj work ror which rhis ,)cn r n n\ucd. I dull tr.r cnlplot any n rcn in an, manmr
<br />$ * ro btcom subir h $c woAcl conrraosd bn l!r'r or Calituhir, did r8r. rh.r il I should tEcom sbjcd b rhd
<br />workm{ .o'npctrsi ion pmvnions ol Ssrn,n l7(X) of rhe Utrtr Cdl.. I shtrll. lonhsirh oniply *irh rhos pmvkio.s
<br />WARNINGT Frilurc ro surc workcrs'conlpcoslrion ovemsc is ,nlxrlll. aiJ shrll suhjcct irr cmPli'ycr k, di irlFMlrar rnd
<br />civil turcs up ro oDc hundr.d lhousund dollEs ($l(r).fin). in rddi'ion n) rhc cosl ofcompcnsarion, datul$s,s Providcd hr rhc
<br />sccriotr 1076 ollhr rjhor Codc. inrcrcsl a.d lllomy \ fe\
<br />"",tuG0 3 20LB ^*,'-*,
<br />DECIABAIION
<br />I hcrchylmmrlndor penalry of pcrjury thsl I m liccnsd xnd.r Frevhbn olChlllq 9(co.rmnchg snh sc.lion ?U)0) otDilnion l
<br />or $. Brsin.ss dd Pmlcsions Codc- ud my liccns t in tull forc d'd .fi.cr.o lAfr.$.t.
<br />'+ft$$J!.3 201b '(t*cfru
<br />C(TNSTRIICTION I FNDIN(i A(IENCY
<br />I herchy nmrn undc, rrnDhy ot lerjury rhar rh.r. h d con{fl.trrn Lndins uscnc, for rhc t.rrortuncc of rhc work for which rhis Fnir i1
<br />issucd tse.3097. civ. c.)
<br />ATILII;ANLIIECIdAAUON
<br />I hcrd'y.fmr u.dcr pcnrlly ofpcrFry onc or'ht roll.Bing dNldilons:
<br />Dcnmlirn,n Pcrnrirl Ast (os Nol ilicat io n ,:cderr I ttcs u lar ions (Tirlc 40. Pd6)
<br />Rcquncdlr(.rofNo l.dion
<br />-l
<br />ccdiry rhd rhc lcdcralrcgul ions EgudinB osbcslosrcmrvlllre nor,pplicabk lo lhis fmicr.
<br />dlcnify Ihd I hr( rc0d rhh utplicarion el surc rhar rhc shrvc inturmridr i\ coflsr. I lsre ro comrly wirh rllcily0ftl Counry
<br />ordirrtrccs.nd Srarc bws Ebriry ro hu
<br />dhuvc nrtrrbncd pmlcny tu iNFcri,nr
<br />ivcs ofrhn Ciry nnd Counrr lo cnrs upon lhc
<br />ADpli.anl orAEenlSknnlurc
<br />Qat +4 A,'-o-
<br />*"qu6 +8 2019
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Translormers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilinqs (T-Bar Rouoh)
<br />[/eter Release
<br />Rouoh 7t</K 711)
<br />Service Meter
<br />7/tzls ?t6Y
<br />Notes, Remarks, Etc
<br />Site-Work
<br />FINAL
<br />lxnd. \ NJmc.
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<br />Lndcr'i Addr.qq:
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