|
ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE IDiSIG.COMMENTS OWNTIT BUILDER DELCARATION
<br />I hcrcby umrn lnder r.nalrr r,t p.rjury rhar I dn cxcnu from thc Co racrr{ Li.cn{ uw forlhc r'ollowin! ro,\on (srcloll5
<br />Busincs trtoI Prorcsion Codc) Any City or Counly Fhich rcqutc\ r ,'.nnil r. con(rucr. Elrer. imrrov.- d.nlolish or rc|an any
<br />ntu.ror.. t,itr k, irs issuarcc. als rcquirc\ rhc alplktnr liJr ruch Fnnir ro iilc 0 si3md dlrcmnr rhrr tr or shc h liccn{d pur{lnr
<br />ro rh. prcvnnnF otrtl Conlitcror\ Lrctrscd tiw (Ch.!rcr 9. Comm'kins wnh sc.rion 7firo of Di!i\n,o 3 .rrhc ausinc$ a.d r
<br />Pn,tcs\ions cidc) or thd trorshc h crcnul thcrcflon lnd rhc hast ror I h. nllcScd crc mpl ion Any vidrri{'n olScdiotr 71r.11.5 hy uny
<br />rmli.a.rraraNnnilsuhjdsrhcapplicu'x,rciviltcndhyornor.mrorh0nlivchunr.{ldollur(s5(x)).
<br />-1.
<br />as ostur or rh. t'tup.ny, or my cmpbyes with *!scs !1 rhdn sob .onr!.nql ion, will do rhe work ukl rlt nfrturc i|n,l
<br />inrcflLd .i ofcrcd lor ek ( S( 70.14- Businc$ !.d Pnrr.\rnnF Codc l h. Conr!rcloi\ l,icctr{ Ijr do.\ trot opdy k' !n ownrr .t
<br />rhc tmpcny wl.i) build\ or i'qnors rhcrsn. lnd who de\ such *oir hims.llor hfi{lfor rhn,uah his or hcr.wn cmPhvccs.
<br />lr.vidcd rhd su.h impnN,Enll m mr inr.nd.d .r ofiftd n, *k. It h.scvcr rh. hdildi.S or imEorcnEnr is old *irhin ok )td
<br />orc.rpLrion. rhr owru Buildcrnillh.vcrhc hlrd.n orp vi'r8 rhar lf or \nc dt not buiB o, nr{novc rhc fmFny for rhc Irln { or
<br />Lr\o*trcr.rrhclnJncnr.anrciclu\irc]yconkNri'rg*irhli..i{d.ontrch6locon{rucrrlrrnic(r(Sc.7t},l,l.lnai'(\t
<br />rrd Ptriri\sinr Codc:'lhc Coirrr.ror'r l.i.ctrsc L.rv docs tror {Drly ro rn o*ncr orPr,r,-iir yho buikk or nfn,vcs rhcrc.r.
<br />rnd wlr .onta.(lor nrh llrcjcds silh trConrrrronr) liccntcd Pui\xrtrl torhcConrrlcttr\ l-ic.trr. hw)
<br />-l
<br />h.vc $n will roinbin ! Ccnirrcarc olcotrrc hS.lf.lnsurclorworkcn.omFnsarion.as Eovidcd ror b, s.crion 1700oflh.
<br />hbor Codc. Ior lhe pcrformancc orrhc qolk for whi.h rhc p.rni n issucd
<br />-lhsv.andwillmainrainworkcs
<br />compenslrion insn.trncc, a\ rdtxircd by Scction 1700.frhc tjb.r Lbdc. fot lhc Pcrfortu..d or
<br />rht {orl lor shich lht pfin l is tsu.n My *orkc6 .r,npcnsxrion insurarcc qtrier lld Erlk! numb.r u.
<br />Poli.y Nunrbc!
<br />-Exptcs:
<br />-
<br />-l..niri
<br />rhrr in rhc ptrfonnincc olrhc s'ork lbr whth rhn Il.rmir G i\rucd. I shrll nol ctrlPloy rny l.^on in lny 'unncrs ask,bcNm srbj.rl lo lhc sorlers'comp.n\ ri.n lowsorcalifornin. r0 lcdihd ill d$uld bccoflE sh]cd rorht
<br />wor*crs.omNtrsiliorpmvisionsoiScclt,n:l7u)orrhcLftoCodc.ldxrLlli,nhwirhco.ll,ywithlhorcprovhions
<br />W RNINC f{ilurc h *urc workcB compens ion colcmse h unlacrul. md shall suhjccl a. cmplorti h diminal lr@his and
<br />civil fine\ ur ro oe hmdrcd rhoustnd dollsn ($100.000), in addirion t! rhc cosl ofcotp.nsrioh. dtro8cs os fnovidcd ror rhc
<br />Scction 3076 ofihc hhtr C.dc. intcrc( lnd orlomy s ltcs.
<br />Appltdnl:
<br />LtcENs[DlQltrnallltl
<br />DIiCI.ASA.IION
<br />I heEby 0lfirm under ncnllty or pcrjury rh,t I an liccn$n u tr pnvnn,n of Charrd 9lconrmncins *iln Ser iun 7tx[) ol Divtion :]
<br />or lhc Businecs and Pmlcssions Codc. und hyliccnsc k in tull roM md etfccr
<br />CorlEclor
<br />colErau(IlaN.r[lDMi-dalNg
<br />lhcE$y3tfiir.undcrpcnslryor!.rjuryrhnrrhcrcn.onsrrucrhnlcndi',sascncyrorih.Dcrformanccolrhcs.!kiorwhichrhiipcnniris
<br />i$xcd (sc. 1097. Civ C )
<br />AITIICANIDECTJEAIION
<br />I h.ftihy of6m undcr lcnalry oI ricrrury one or $c followinS dcclual ions:
<br />Dcfrnirion P.rnn$ stEsros Nolification F.d$al R.guhr ioN (Tirlc 40. Pan6)
<br />R.qun d kxcrof ll,tifierion
<br />I .erriiyrl{r lhc lcdcBl rc4ularions rcs[dirs nsbc(os rcmovrlarc nDr |rllrlblc to nris fniccr
<br />-l
<br />ccnifyrhlr I h,k rcrd rhis 4plicalion and stalc lhallhc otnlc innnnurion is corcl I esrc ro NnlJ)ly e irh all Cnv nnd Cr'! v
<br />ordinamcs and Sllrc L.f,s rclrring ro hnihnrg .onslDcrirn. ond hcrcbyluh,nzc dprc{nr,tiv.s oflhis City atd C.udtylo enls u,nn lh.
<br />ah)lc mnrioncd tmpenyn, inspcciion purTx,rs.
<br />,\pplictrnl o. Atenl SiBn.turr
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Bondinq / Groundinq / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Faclory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinos (Hard & Soflit Bouqh
<br />Ceilinqs (T-Bar Rouqh)
<br />lvleter Release
<br />I 1
<br />Rough ,t2 )
<br />Service [t/eter
<br />FINAL rl b E -l;4rX\,\P).1 1+))
<br />Notes Remarks Etc.
<br />I mcr.m.r undcr S(non .B &PC.forrhNrcr$,F
<br />D.r. O$n.r -
<br />]TAatrISU.COMIENSAIION
<br />DECLA.IAIII,IN
<br />I h.rcbv amrn undcr Dcnally ol ,l.rjury om of rhc follo*ing dcclrathns
<br />lrndc, . Addrc*
<br />Under Slab / Floor
|