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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrcb, aflirm und.r pcmlry or 0.ijury rhDt I m cxcnul fror thc Co rudrK l,iccnsc La* tor lhc iollowins rcn$n (Sr 7o3l 5
<br />Businc$ ff'd Prolc$ion Codc): Any Clty or Connry whi.h r.qui(\ r rtr rir ro snnflcr. dlrcr. nn rovc. &trslish or mrdn any
<br />stu.rrc. ri, ro ih hs{ec. lls rcqoncs lhc arplkanr r'or such peilnn ro nk . siSmd (itcnEtrt lhd tr or shc is liccnred punurnr
<br />ro rhe pmvisions ofrtE Conracrols Liccn\cd tjw (Ch|pr.r 9. co'hmi.ins wnh Scdk,n 7000 .f Oivi\nrn 3 ol rh. Burincs 6d
<br />Pft,rc\si{,nrCodc)orlblrh.orshcneicnrtrthcrclomandthcb.s^forlhcal,cSencxcmplion. Anyvi.lnlionofSc iotr?011.5nystry
<br />lrplic.n( Ior . rumn subjca rh. Lmltuanr b n dv il pcMlr y ot mt nnnc tl[n nvc hundrcd dollar (S5m I
<br />l. ,r o*nct nf rhc popen y- or my enployes *ilh N!3cs 0s thcn sh compctrsarion. will do rh. eo.k aM rhc sltu1urc h ftn
<br />inlcndc.l or oficrcd lor slc (S( 7044, Busim$ and Pn,fcsions Codc Thc Con,r,croi{ l-icc.sc lls &,cs nor llplyi. nnowerof
<br />rh.rmFny sho ioild! or itr{mvcs rhcmn. and who dtux $.h x,k hins.lfor hcrslror rnror8h his.r hur own cnqnoyccs.
<br />providcd rlDt such nnrlovcm.k m ior inrcn&d or ofcEJ lar solc ll howcrcr. rh. blilLlirS or inDmrmnr h sou uilhrn unc Fir
<br />ofconplcri{ (lr Owncr Bliu.r will h.vc rtr hurd€! ol [ovirrB rh.r hc or shc dil .or tDik or inpmr rhc pnl,).n] lor rhc l,uqDc of
<br />_1. isoa,rfiof rh. pmPd y, anex.lu\ivdltcontacri'rs sirh liccnrd colnrrnnhcon{rucr lhc lrni{r (scc 7041, Bu\mc\\
<br />ntul l\l)fs\hr Codc 'lhcGnrrrlcrols Li.ctrsc Ltrs docs tror rrrflyk) rtr.q cr of,)flrFcny who builils ornnriovcs lhcrco..
<br />lnd Nho .onlmn r.r suchpiojc.rswirhsCo trcbrl,liccns.d pururnr toih.Conkacntr s Lkcnr tisl
<br />ldtrrcrc tnu (l.rs..rnnr .tl &1,(. larrhlsr.rvn,
<br />.uatf,l:f,.rrallfliNlauaN
<br />DECIdA6.IIO!
<br />I hcr.hy llftn undur pcmllyolrErjuryon. olrhc rollowin! d*lrrJrtnK
<br />lhrvcandNill.Enain!CcnilicllcolConscnrhScll.l.suEforworkcF€np(tr\dnnr..\prcvtdcdlorbySL{ion:lT0oolrhc
<br />Labor Codc. ror I hc perlornumc of rhc worl ltr which rh. tdrir ir i\ru.d
<br />_lnavclnduillnrinrnirqorkcscomFnsalionnNurlnc.rsrcqutdbyscc'n'nl70oolth.Liho.cod.,lorlhcFrfoirmnccof
<br />fic uo* tu *hich rhn Frmil ii hslcd Myworkc$ comp.nslion insuERc c,nicr 0M Frl,cy trumbc! uc:
<br />l.rdiryrhlr inih. pcltonroiccofrhc a1trt l rhichlhh p. nir is isucJ.l shrrlnot curtlr,yan, pcson iD,nyflunncr
<br />s s h hcoff $ftjcd ro rhc vDrkns ..'npcnc n,n bws ol Caliiorni!. lnd r!rcc rh irl \horld l{conE $rid hrhc
<br />+t*ss.omFnsariotr,iovrsionsofsc..rrcnlr00.frhcltrhnGrlc.I(hnll.fonhsirh.onplysirlrh{phri\nnr
<br />TyARNINC: Firinrc b cclrc wo cr' conrlEnsrrnr ..v$igc is utrh\rul. Md shrll suhFcl .r c rfk)yn ro ai riml NMllics rnd
<br />.i!il fincs !t lo om hundrcn lhousrnd doll s ($100.fix)). i[irion lo rhc con .l comp.nsdion. da'u8cs us prolidcd for th,
<br />s rion]076olrhc Laho, Cdq inrcrc( i.d utrorrcy s r{\.
<br />Appli(nnl:
<br />I hcrcby (liinnundcr pcndryoftc4ury rhd I nnr li.crrd ion otChafrd 9lcomnrncing *irh S.ctiin 70(n) ol Division:l
<br />I hcEby !flirmundcr lrcndtyofpdjury lh rh.i. i{ o Lrn ruct
<br />ssucd (Se 1097, Cir. C )
<br />r!.n()_ ttr rh. ncrtui,mmc ofth. *ork ntr {[irh rha n nni '\
<br />AIfIICAILI]ECI,IIf,AIA!
<br />I M,yafflr un'l.r Nntrlry.rpcrjuiy o.c.rrh. fdlo,ir8 dc.la,utions
<br />Dcmulirion Pcirnirq Asb.sos Noriricarn i Fcderul Rcs!lutions (Tillc40. Pln6)
<br />*Rqtuircd hucr ol Notilicari.n
<br />-l
<br />ccrliiylh4 thr ri{crclE8uhlion\ rcBrdirS astEsos rcnmv,l {c no!,ppli.ablc ro rhis prulccr
<br />-l
<br />ccnililh0r I harc rctullhis itplic,rion srrlc rhar rfu abv. irfonMr i(,. rs .orccr I rgia ro omply wnh ill C y and C.utrry
<br />ordnrB-^cs md Shrc L{ws rldirS of rhi\ Cny rnd C ()uf rt t).nr.r !N 1hr
<br />nlc N ri{nrcd fn,rny,n'
<br />/\ppli.rnl or AAtnl Si*ndlu
<br />Undgrground
<br />Pole Bases
<br />Light Standards
<br />Spras, Pool, Fountains
<br />Signs (monument)
<br />Lile Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Root Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilin s (T-Bar Rough)
<br />Bqugh qtq6 \rn^,le,27)
<br />Service IVleter U \
<br />FINAL b I i-zY'rrr,"+ t afi)
<br />Noles, Remarks , Etc.f[l \a=-
<br />Site-Work
<br />Ivleler Release
<br />,,1 rh( Btr\i"r\ rnd l1otu\\i(r\C.dc. nl trry i..n\. n i',lul
<br />C-"*".\
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