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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER DUILDER DELCARATION
<br />I h.tutrt amrfi und.r pcndlry of Friury rhdr I mcxem fmn rhc Conrr.hn l-kcns bw tor lhc f.llowinS- rcn$n (Scc.703l.5
<br />tsusinc$ aln Profi*io. Codc): Any Cily o. County which Equics a pcrmil to conslrucl. flllcr, improlc. dcmlish o. qi{t any
<br />srtocrurc. Eior ro irs hsuame. rho Elutcs rhc ryIltonr lor such Frmir ro filca sisncd sralemnl rhlr heorslr t\ li*nscd ru. onr
<br />k,lh. pmvisions 016. conlrack s Li.cnsd bw (Chnprcr 9. c.nncftin8 wirh Sccrion 7fiD olDivnn lofth.Busnt$lnd
<br />P,llcssions Codc) oi rh{t tf, or she is cicmpt rhcrcfrononn rhc blsis lor rhc ollqcn cxcmflion. Anyliol.rionolSdliJnToll.t by 0ny
<br />,firlkafl for d pcmn slbj(ls rhc {,rlicsnr r., ciril I}.naltyofftn m,c rh!, fiv. hu.dicd dollarq (l5m)
<br />lN. * .**r r,* o^,*nn o. my cmphy.cs wirh wrscs rs rhcn !,h onpcnsar ion. will do rtr *o,k n IlE $xiE n nor
<br />inlcndi or ofic..d for slc (Se.7044. Busitrcs .nd Pmfcsshns Cod. Th. Conl!0dols Licctrs Llw docs nor opr y ro M o*ncr ot
<br />rhe ln)tEny who huildror inpturcrrh.en, and *ho dms xuchs hihscll or hcrklf or rhhu8h hir or hn own.npl.yccs,
<br />pruvidcd lnd slch inv,mrmnrs N ml inrcnd.n or offcrn ftr sk. lt lrwE. lh. buildioe or i,rmEnr n sld wnhin o*
<br />'ttroI ongldbn.
<br />'rE
<br />osmr auit r wil h,rc tlE hdcn of Imvine rhoi rh or sh. did nol tu d or i,n0mw lhc ImIEny fr rhc prrFE oa
<br />-1.as.wncrofrhclronny.0ncxclusivclyconrrlcrinswilhliccnscdconrracrosrocon(ruclrtrrmFrlScc70.14.Bu$ftt\irl lrrDtusdn Cod.r Thc Conhncror's Lic.nsc Law docs nor amly h mown r ofpn,lcdy *ho builds or inrprovcs lhercon.
<br />ud Nho coorrach lor such prcFh sirn a Ornhcro(g ltenscd ru6u r ro rhc Cont&ttr sLic.nscllw)
<br />-l
<br />rDqcmpl utrdcr Sccli
<br />t-,=l-l
<br />DICLABAIIO!
<br />I lrcrcby !flinnunder penrlryolp.rjuryo.c of rhc lollorvins dccliririons:
<br />IhavcandsillnuinrriDoC.nificar€ofconrnrI.S.lllnsurctr!qo crr.ompcnsari,n,, a\ pnrvidcd for hy Sc.rn l?0Ootrhc
<br />Llb.r Codc. ior rhc lclforromc olthc soft for which rhc pcan ir nsucd
<br />-l
<br />hr[ lnd*illnri oin so,kcn coflrpcnsariotr insurancc. as rcquncd hySsrnnr]7(notrhc l,horCodc. ftxrh. lcaforruNc or
<br />lhc nuk lbr rhich this p.rmir is hsucd. M y workcn conrEnsarion insunrcr clricr xnd Ix licy nu'nh.r ,ft:
<br />LN{ *a,ry rh ii thr p.fd,mn.. .r rh. work rd whi.h rhi !.rml is n*ued. I \hnll nor ctr[loy rtry p.mn in $y monncr
<br />xr as lo tto!rc subj.ct lo lhc workcs' conD.nsal ion laws of Californi!, otrd rBE lhal il I sh,uld tEcort suhjccr r. rrtr
<br />*oltca conU.nslionImvhions of Scriofl ]TOO oflhe Libor aodc.I sh.ll. ionhwilh srylt eirh rh.s rFviaions..
<br />Scdn r 1076oflhe tih, G)dc, ir crcn nxl.lioary\ a.cs
<br />r,,",'OE\b ^t(
<br />^pp,ic.n,:
<br />!<-
<br />Ll!-t !rr!xoIl&\t_I2lt
<br />DS:IdAAIIQN
<br />I hcsb, lmrmundcr pcMllyofperjurylhul I an liensl under rrcvisionolChoplcr 9 (mmntming wirh Scclioh Tuxl) ofDivision l
<br />ol lhc Busircs md Pmicssions Codc, ond my liccnsc n in 6i ll ior.c dcfl(l.
<br />CON BUCUOIIIND,IIC.ACENqI
<br />I hcrcby ,ifirn u.dm tfnaliy of pujury lhal lhcrc is a .on(dclb. lcndi,rB qcncy for th. pcrr'onMe of lhe lork for whth rht rEmi ir
<br />irsucd (scc :109?, Ctu C ).
<br />AIPIICANI.DECIdSAIIIIN
<br />I hdrl,y anim undcr rcndlty .f r.rjury oic or rhc followin8 delml bns:
<br />Dcmlirion Pcrnih-ArtEslos Nolificalion Fedcnl Rc8ulalions (Tnt 40. P!n6)
<br />-Rcquncd
<br />t.nfl of Nolifi carnn
<br />I ftd iay rh0r $c Ld.ral nBulalions Rgarding asbcsktr n'tuvd m ml lrrltablc lo this poj.\t.
<br />!d eiily rh.r I harc rcd rhis trpllic0rion s'd srardhrr rhc,t[rc inrdnurion nconsr. lacrc rocomplyvnh lll cary and counr,
<br />ofllinimcs and sr.rc tjws rhrin3 to building con$ru.tio...Id htrcbyaurhori- rc[cscntalives ofrhis Ciry d Counry k, cnrd uFin rl*
<br />rt vc trrnriohcd lmncny ttr inspcct ion lury'*s
<br />L-
<br />Applicmt or Agenl siamlure:
<br />,"*u* *.",0n*,(d6ru.d o9-$-r9
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundino / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />alls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Solfit Rouoh
<br />Ceilinqs (T-Bar Rouqh)
<br />Meter Release
<br />Rough 9t 'l flr7a)
<br />Service [,4eter
<br />FINAL 4 l?/r3 I \rry-\^ e/r f:n\
<br />Notes , Remarks, Etc.fr U' \-/
<br />-+,
<br />5 "**.)a
<br />tf,nd€' s Addr.$.
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