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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUIDER DEI,CARATION
<br />I h-rcby affirm undcr pcnalry ot pcrjury rhat I am cxcmrr from rhc Contados Liccn\c liw f.r rh. followin! rcrsn (S 70:ll5
<br />lrusircss dnrl Porcsi.n Codc): Any Cir, nr Colnry whi.n ,cquircs 0 lqnrir ro con(rud. drcr. inrlrovc. d.mohh L{ rcD . otry
<br />iddure. p,ior lo irs issunmc..lh rcqnncs rhc,rplicanr ru strch Firnir ro lilc ! \igmd sllrcmnt thar h.or shc is liccn{d puruanl
<br />ro thc pnrvGions ofuhe Cont0.r.r'\ I-i.ci\cd tjw (Chlfrcr 9. CoNrrncins *ilh Scdn,o 7mo ol Division I ol'rhc Busixl$ and
<br />PronsionsCodc)orrhartrorshciscxcmprrh.rdrohmdrhcl'!\hrrthcalhBcdcrcflrptn,n.An!vioklionofSecrhnT03l5hrBny
<br />npplica lor ! pcrmit suhj(ls rhc a,,plicanl lo rcivilpcmlryothor nx,torhrtr nv. hundr.ddoll{\ l55m)
<br />-1.Nrwtrc.olrh.ln,Fdt.ornrycmplotlcswnhwases!sthcnshcoryensrion-wi,ldollEwort,lhcslulucFmr
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<br />inrerncd or olttEd lor slc (Sc.70.14. Busincss iM Prore*iois Conc: Thc 6nract, r l,iccnsc lrw docs no! arply ro an.wncr.l
<br />rhc pmFny who ttuilds or inlp(rs rtccr and *lF des sf,h sork him{lf.r h-r*lfor th,uBh hh or h.r own.mpk,yc.s,
<br />pmvidcd rhal such inl!'orcmnN !rc mr iNcfrLd .r ofibrcd fff strlc lf, hoNevcr. rh! htrildins or imrrcvcn.nr is \old wilhin ..c yr0t
<br />ol orphlbn. th. Oa.cr Buillq will tu\r th. bxrdcn of pmving thil tr or sh{ dil mr hoild or itrYmr lh. Impcny for rrE plqnc ol
<br />l, asowncroirhc pmDcrry,0mcxclusiv.lyconk lin!wirl lic.ns.d .unrnci,n n, ..nsru.r rhc prtrcr (Scc.7044. Bu\irr\\
<br />rRl PniixsionCodc: Thc Cont,ctr\ l-ircnsc l.!w d{rcs mt opplyro r o\,rcr oi proFny *ho bu ilds or nnprovcs rhrcotr.,nd sho conrocls tu sucn rreicrs uirh a coDrnckrls) li.cn\cd rulsudtrr k' rhc Conracrn r l-icinr ljw)
<br />-l
<br />a cxcnrpl trndcr Sc.lion , B. & PC forrhi\ i.r{rr
<br />Dole: O*ner:
<br />ivoRKFRSi' C0r[rPl'NiSATrcN
<br />D&CLASAIIAN
<br />I hcrcby firnund.rn nnlryolp.rjuryon. of'hc following dcclarlli.ns:
<br />-l
<br />h.vcrnlwill m8ihrain aCcnificurcofConsnrro Sclf-lnsurc tu sorkcrt coflD.nsrnrr.0r pmvidcd for hlSccrionlT0Oolrhc
<br />Lrkr Codc. f(trrhc pcrfornrncc o I r he sork lirrwhi.h rhc pcrn ir tsucn.
<br />rhc work lir wlrichrht ltnnn rs issRd My w.rl.ii .onrFn\di{'n insurrn(crtricrrd Fnic} numhcr rrc
<br />adrrr:
<br />PolicyNumbcr:_Erptcs
<br />I.cnirrrhar inrnc pcriormncc ol rhc u,ork forwhichrhr,. nir n ssuM.l shallmr cmtrkJy rtry p.r$. h a., nrnncr
<br />s rx lo h.$nf, suhFr ro rh. wor[r^'comFn\ai ion hws of Califonri!, oad (3N rh i,Islnuld bc.om {hjcd rorhc
<br />worlcs' cotrp.n\d n,o povi\n,d! or sccrnri :l7tx) ol rhc Lnlry Codc. I sttrll, fonhwirh coq:ly * ith thos lnvni.ns
<br />WIRNINC: l:lilurc to sccurc qorkc( conrpctrs ion.ovcrasc is u hwrul Jar n, .rntrtrrl F1'rli.\ rnl
<br />.ivil nncs up ro onc hundred rhousa dollan ($luJ.m0). i. lddirbn drnugcs rs ln,vidcd for rh.
<br />::::?Fibr,{*
<br />I hcrcbtrtltmund.r!.mlryolpcrlDryrhrr I m liccDed trklcr pnJvNi( .i(-hntr
<br />oI rh.llurim$uM Pr.li\siur\ Cod.,.rlmy li.cr:c i\ in tullturccr drll..r
<br />9 lcomnErcing wirh Sdr irn 7O(X)) of Oivirn r l
<br />-Li!_crsc
<br />Nunr
<br />I hcnby rfinn u.df FtulryofFrtrry rhar rhdc h E con(ruclion
<br />istr.d (ss.:lO9?. Civ C )
<br />rro.cc ollhc {ork tor*hich lhh pcnn n
<br />APTUCANLIIECIdAAIIAN
<br />I horby !fiim undcr pctrrlly ol p.rjur, onc ol rh. r.Uowiis d.clffarion\:
<br />Dcnmliriotr Pcnnns Asb.so\ Norin dion F{d.rilRcEullrior tTille 40. Pan6)
<br />-Rcquicd
<br />t rlcrof Norifictrtion
<br />I rcni!rhrr lhxvc r.rd lhi\rpplicrrnnrrtrd rhl( rhcnhrvc i nnn{idr i\.onccr I rlrcc kJcotrvly sirh rllciry (trd cotrnry
<br />ordihn(\ md Srrrc Irws rc[ring robuild rizc rqrcs .tn$ of rhnCny{.dCotrntytocnrcrun trthc
<br />".,,/r/,/
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor rl I
<br />Bonding / Groundinq / UFER \\g\\1 AM1lt1
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />lValls (Rough)
<br />Ceilings (Hard & Soflit Rouqh
<br />Ceilings (T-Bar Bough)
<br />lvleter Release \\s\\q ANLOTIq I
<br />Bough
<br />Service ltrleter
<br />FINAL \\a\r1
<br />^Mclt'
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<br />Notes, Remarks, Etc.v
<br />Sions (monument)
<br />.-'-"*. (
<br />tIn,lc.r
<br />^J.ln-\
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<br />ccnilylllal rhc lcncril rceularionr mBlrd4 i\tr{os rcnn,lsl ar. nor rrp icnhlc tr rhirtorcci
<br />rh,!c ntr ii,,r,ltr,txdv fii in\p.cinnr
<br />Appll$nl o. AE€nt SiAmlure
<br />Pcm lentrn€(prinl):
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