|
ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.OWNER BUILDER DELC RATION
<br />I h*cb, amrnr lnder Fnalt, oa !€rjrr, rhar I am cxcmfl fronr rhc ConrrrcroN l-iccnse liw f.r rhc nrkNin8 r.nsn (S.c 7011 5
<br />Busi.css dnd Piore$ioi Codc): ]\ny C y or Coxdy whkh rcqut s d Fmit ro .on$fl.r. !ncr. inrm\c, dcmlht or rcItir !n,
<br />(ruclurc, I'rior to ns issumc. ako rcqlncsrhc applicd for such ?cnnir to nlc a shmd (utcnEnr lharhorshc k liLtnsd ruhxanr
<br />lo rh. rov(ions orrtE Co.kr.rors Lic.nsdl bw (chrflcr 9. connmRin8 wilh Scclion 7uD of Divnio.I ot rhc Blsi'rcs\ rnd
<br />Pmfcsion\ Codc)orthal h.orshc h cxcnrfl IhcrcfroDnnd ltu hast for the !l lcBcd cxc n{'l ion AnyviololionofSerionT{rll.5bya.y
<br />nptliconr aor o pcmit subjcck rhc optliclnl to rcililpcntrhyofml morclhan fivc hunnrcd dolh^ ($500).
<br />-l.a\ownc.ofrheDropcny-ormycnrpby.c\$ilhsa8csaslhcirsolecoryrnsarion.willdorhcwolkrdlh.{u_turcismricnl.i.rofltddforslc(S.{104.1.Busi,rc$..dAor.s\n,n\CodcTh.Cofti.ktr\Lic.nsctiwdocsmtau,lyloaoowrcrof
<br />rhc pmpcny who builG or inr()rc\ rh.E,.. aNl s hr des irrch Nolt hnnscll or ncr*ll or rhmust hh or hcr o*n c rployccs.
<br />prolidcd rhar su.h tnimruEnrs m rr inr.Mcd or.rcdl rir qh If. hacv.r, rh. bxiHnE ur nNtuvcnrnl is bH *irhin onc )€r
<br />oi.on{,krn,n. rh. O$ ncr Auil{ls qill h.v. rhc hordcn of ln,vin8 rhar hc or shc did nor hxild or inptuv. rhc lnrtMy for rhc t'urpos ol
<br />I. d owncr or rhc pmprdy, nm e x.lu si v.lt ..nrir.r ing eirh li.enr.d $nlh.tns tu .otrslru.t tlE l,lFcl (Scc. ?0+4. R6in$\
<br />afrl Pn,tssion Codc Thc Cotrraclor's Liccn\c Low docs not {fly nr u owns ol pmrEny sho hn ikl\ or imp.ov.l rturmn.
<br />aM Nho co.limh ror such pmj(h wirh. conrm.rlds) li.cnse rur*urN r,rhc conractolr LiLTnsc hw).
<br />l B,ncrcmpr uM.r Scclio
<br />UIIBSESII;AIIIENSAIII)N
<br />DSCI.A8AIA!
<br />I hcrcby afflrm undf ,,.mlly of tdjury onc of lhe folbwing d.cLnlions:
<br />I h.vc ar] willrEnnrin a Ccniticalc ofCons.n . Sclf Insorc {o. w.rkciq .onpcnsalion. rs rovidcd for hySccrion 37(Dolrhc
<br />Labor Codc. for lhc lcrfonMncc of thc *ork aor *hich lhc psn l h issled
<br />-l
<br />hat &nd siu msinr0in so ers conpensarion iNlmncc. as requtcd hy secrn,n]700orllr ljh.r Cod., ior lhc PcrforroEc ol
<br />rhc*.-ltnr*hEhrhhNrm:ri\i.\u.dMtworkchcomNntariolin\ursns,ori.dIslitndmb.rd.
<br />."* - SJ-r.[., frr' r.-^,
<br />? "ti".r N"^6
<br />",
<br />/---gp!z-bf b-fr 3-
<br />I.c ily Ihrr n rh. Nrfoi,nrmc ofthc work ttr which rhi\ |Fi,n( n isndl.I shrll nor cnrliy trry pcr\otr i', rny mrtrncr
<br />v' i, bcomc suhjLrr ro rhc workcri .o q, p.nsrr ion hw\ .f Crlir'orn ir- i rsrcc rhd irl nx,rld br.o'ft \uhjr{r t)rrx
<br />$.rkcF.ompcnuli{,nptr)vi\i,,tr\otSccii,nrlT(xrofrhcl-atxtrC.dc.tnnlLfdhsirh(uPlywirlrrlr\cI)(,(Niotrs..
<br />WARNINC l,trihtrc to s..^urc qorkcs'.omr.n$ridr coverusc is utrlawlul. llrd rhlll suhl.cr rlr cmnk,ycr h.ri inrlp.Mlrics 8trd
<br />civil rinc\ u, ro nnc h!.drcd rhousrnd dollars (Sl(x )).ir{ irnnr ro rhc cod oi c{nnncns n,n, dr agcs.\ povid.d lnr thc
<br />Sccrnnr 1076.llhc Llhor Codc. inlcrc{ and arktrEy
<br />,.,",* 9.-\q-\b
<br />I hcrcbyaffir undcr pcnalry.fr,.rjuryrh{ I a licctr\.d ntulc, Eovi\ion olChrprd 9{c.nmrn.ine wnh S..rion l{XX)) olDivnion l
<br />ol lhc Busi.csand Proit$ions Code. and,ny licemc is in tull lorcc ond cnccr.
<br />C6?\ 6-2I.t\ (
<br />rur" n r9.\)
<br />IOISIBIJ(:IION.LENDING.AGENCI
<br />I hcrcty !fltmundcr pc"ahyofpcrjuryrhar lhcrc ha c.n(Nclion lcndins arcDcy i{n rh. prf.rrun orrhc s.rk lor which rhn Frnril is
<br />isucd (Scc 1097, Civ C.)
<br />AITIICANfIIECI.AAAIION
<br />I lEtbyallmundcr pcnrlry oipcrjuryonc.f lhc followin8 d(larution\:
<br />Dcnrlirnn P.rmirs Asb.{os Noriicarion Fcdcrul R.euk n,ns (_tillc 40. P,n6)
<br />R.quind trn* orNodi.dion
<br />I ccnilyrhlr thc rcdcral rqukrn ns Esudin8 asbcsros rctrrul rc rcr$plictr$lc h rhis pn,jccr
<br />.Rlitu c.s rnd Srdc U8\ rcL{n'8 k iLinrg..trn'acri{nrNlh.rchyrurlx,irctfrc\$lrrivc\.1rhL\C-'ryrD Cornryticnrd !F)nrh.
<br />rlitrc trf,nrion.tl Imn.ny lir i,
<br />,\ppli$nl or Agenl Sianxl
<br />\Aar-"t t-\1 zt-
<br />ill $
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spag, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Faclo ry Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soflit Rouqh
<br />Ceilinqs (T-Bar Rouoh)
<br />Meter Release
<br />Rough gtb r<l*Ixtr)P 4)
<br />Service Meter tl 'ol
<br />€rnrz //)?
<br />Notes, Remarks, Etc
<br />COMMENTS
<br />Transformers
<br />FINAL
<br />?.rz lr. r 6
<br />t odcrs Addrcr'.
<br />-
<br />Icc ilrrhrIhJ\cre rhnrpplicrrionmdnrr.rhirhcatrvcinlnirnrln n.Dnccr IrE(n,c.rll]lysirhrllCilyi C.unll
<br />I
<br />-------r-----
<br />I
|