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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDET DELCARATrcN
<br />I hcrchy 0ifirm undcr p.nally of pcrlury rhd I m crcmpr rrorn rhc Co.rrr.ros Liccnse hw for lhe followins reaen (S<.?oll.5
<br />Busincs a"d Pmfesion Codc)r Any Ciry or Counly which rcqutcs tr lcrmn to consrdcr- rltcr. improvc. dcnhlirh or runtrn uiy
<br />{rudurc. pnor ro n\ i$uncc- aLso rcqun$ rhe apDlic"nr for suci pc.mir b filc r \ised {,rdftnr rh, h. .r shc i{ li.cn(d pusua
<br />lo lhc pmvisions ol tlE ConlEctols Liccn*d Law (Cha cr 9, consEmir8 Bilh Scclion ?000 olDivhion.l ofrhc Buiin.$ and
<br />Pn,ac*bns Codc) or rh( t( orrh. k eicnDr rh.rcfm'n and rhc hasis a{, rhc alLgcd.icnllrn,n An, violdi.nofSerionT03l5 bt rtry
<br />0ppli.rnr for 0 rcrnrir subr.cls thc iltliconl
<br />'o.civilpc.0llyortur
<br />mr.rhM tlvc hundrcddollais (S500).
<br />L as owner or rhc I'oreny, or d, cnrlloJ,lcs wnh qnscs B\ rhct slc comPtnuidr, will do rh. work Md ltr stnxlm h nor
<br />irtdicrl or orcrcd lor elc {Sa.?044, ausim$ and Pnn'.ssions Codc Thc c'onr.crols Liccnsc Lrw docs nol lmly ro !n owncr ot
<br />rhc ptr'pcr1y who buili\ or imrmks inec,n- !'rl wln das suh *r,* hinNcllor hcrclaor rhmush hk or hcr o*ncmflort.i.
<br />,,mvidcd rhar such imtmvdm*Nfr, inrcrbd oroflcEt I(r slc Il h,Mr.r. rhc boildiu or inI'mEm issldvirhinonc )cru
<br />of.odpkrion. rtr Owmr Builde, *ill hlk th. bnr&n of pbvins rtsr hc o. \h. diil mr boitl ur int{hvc l}e pmtfny for tlE prrlne iil
<br />l.rsoqkrdfrhcfl)tcdy.r'n.r.lu!i!cly..ntcrirtwirhli.chcdcortrktribconliruclrlk,mjcclisc!7Or,1.Bu.i"cs
<br />a'rl lh,lisinGxlc:'IncConrra.ttr\LicrtrscLf,Nn{x\norlpllykrrnowrrolptup.ntwh(Jttrild\ormfnrv.srhcrcon.
<br />rnd wh. .oikr.r(nrnr.lrrrol..r\ qnh rc.nr(rn(\) licc'unnrn) rh. C.nkaeis t-i.cn{ t-r*1
<br />-W\H
<br />DA;!Tf,A.II!JN
<br />I turchy amrm uadcr pcnlltyolpcrjuryom ol lhc lollowin8 dNlmtions
<br />-l
<br />havc andsill nrinroh aCcnilslrcolconscnr roScll l.surc r'or sor*e co.Dcnsri.n.ds tovidcdlorhySerion37(Dolihc
<br />tilxtr CMc. lor rhc pcrLrM.c of dc work for uhih rhc l.nbil i\ hsucd
<br />Ekpito\:
<br />I.cd,fy rhar in rhc n d.rm... ofrhc work for which rhn [l.rmir is is\ucrl. I shrll nol.mploy any pcron in floy nruncr
<br />$ rsh hccorrc subjcct to thc workcrs compcnsation laws ol C.liforni{ md uruc rhar itl should trcomc slhj.cr k, rh.
<br />workcs.onr,tnsitiontrovhionsotScdionlT{x)ollheLrhorCodc.lshdl,hnhwirhconrrlywirnrhoeprovhn,n\
<br />$ARNIN(i Failurc h sc.u'. *orkc^ .otr,F-tr\rrnr .orc.xg. n tr',shau suhl.rr 3n cnFotcr lo riminol lleulrlr alxl
<br />.ivil lnu up r' o'r hutrdtud rhousid dollr\ (S|(D.(XX))of.omrcns.rion. dnnuses rs n,ovdcn fo. rhc
<br />,,.,. - gg11t f rQ
<br />^,,,
<br />DECI.AAA.ISN
<br />I hcahy lifi,m under pcnalty of p.riury lnal I !'n lienEn under !ruvirion orChaflcr 9 (Nn'tuking wirh s..ri.n 7filo)ofDivisiotr l
<br />ol lh. Busircss md PmLssions Codc, rnd nrv liccn$ is i. full fore and cfld.
<br />CoNSTRUCTION I TNDN{i A(iENCA
<br />I hcrchy nflnn undcr Frrlryoipciury rhrr thcrc is r.on(ndio. hndin[ qcmy fq rhc l].rli'nru.c orrhc work ror eh,ch lhh Nrnn is
<br />hrucd (sdc 1097, Ci!. C )
<br />Lcndc* Nam:
<br />-
<br />AITJJCAII.!&CLABAIPN
<br />I Mi, atrm und.r Fnaxy or lErjury om of lh. followin8 dcl{d ions
<br />D.rchion Pcinir\ AstEsr.s Norjtic,!ion F.d.ml Rcgul,ri,ns (Ti!l.,ao, Pan6)
<br />-Rcquned
<br />lrt|cr of Nolifioiion
<br />I ccnilithal rhc l.dcml rc8ultrr io ns rcgrdin8 ashcnos rcnrral irc n.l {'/tut'lc ro lhis pnjccr
<br />lcrnllyrhlr ! hrk r.r ihi\
<br />onliDrn..sa Sr?r.liwsrulxri
<br />inaomri{,' n .or.rr I rer€ ro .oin ly wirh .ll Cny a.d Connlr
<br />.by aurhoiizc rcfrc$ntdiws orrhis Cnyand Coutrrr ro cnrcr upon rhc
<br />lhovc nrcnlioncd prcneny rbr n
<br />A0Dlicnnl or A*cnl Si* .lu o(l!7/t3
<br />Underground
<br />Light Slandards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safe ty /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<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 & Solfit Rouqh
<br />Ceilings (T-Bar Rouqh)
<br />Itlleter Release
<br />Rouqh
<br />Service [tr]eter
<br />FINAL g.2q- B l*ta4.,rrd
<br />Notes, Remarks, Etc.
<br /><.,
<br />I
<br />Site-Work
<br />Pole Bases
<br />-l
<br />hivclnd *ill mi ain workcis co.rr.nslrion inru'ursc- &s rcqui.cd by SNr nn, :17fi) or rh. lltx, codc, ror rhc p(formncc ol
<br />rhc work fr shich rhispcmir ii istucd Mywo'k6s cohpcnBrion insuranc. orif ,rl !.li.y nunb.r dc:
<br />I
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