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ELECTRICAL-INSPECTOR HECORD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />-l-
<br />aso*ncrolrhcpmpcnr. ancrctusntlycunkn.ring anh lr..nscd.. rn.r()n ro con{tu.l rh pmF.r (Scc.7044, Bunncs
<br />rnd Bal6sir Codc: Thc ConkNrois Li.cnse Law docs nol lpnly ro u owncr ofptuFny who huilds or imorovc\ rhcrco..
<br />rnd who connrcrsrnsnchrhj.chwilh 0 Conta.tor(s) li.c.scrl pursuonl hrh.C.trtrctr's Lic.nsc trw)
<br />I rn' c1.D,tr undcr S(r
<br />l)drc: ()sner
<br />lV( )RK l,-RS, aor\ri'ENSA ItON
<br />DIiQATAIION
<br />I hcr.ht rmflnrndd pcnrlryol trrjuryonc.l rhc lnlk,wir! dc.hrlriotrr
<br />I hsvc ari will minrain a C.nificltc of Conrcnl to S.lalNurc foruorksr codp.nsdio.. rs pmvklcd lor by Sar ioo 37(x) of rhc
<br />Lntr. Codc. for rhc pdr.@n.c or rhc work fn which ln. pcrmil n ks,cd.
<br />zl(vc rna wlrr mrlnroin wo,km con,rcnsarion insorarcc. us rcqutcd hy sccr t,n 3700 or ric kho' G,dc. ror rh. I!.rrommc or
<br />iss$d. Mysork.rs cunpcn\alion in\un cc.!rid and lolicy nunrhct m:rc
<br />ca-)c_a79 z_.-,
<br />-l
<br />ccf,iiy rhrl in lhe nerrorron.c ofrh. w.rk rd whih rhis l.rnir ir irsudj. | $1ll norcoDloy,ny p.r* in,nyn'.nncr
<br />$ r\ k, bccom srbirr r. rhc qorlas conEnsalion hws ol Cllifornia. an lgrc har ifI stbnld tE onE suhicr lorrE
<br />work.rJ $npns,rio. povki.ns ofSaln,n 3?00 ofthc trtxrr (odc.l shal!. ronhwirh conrnly qirh lhosc Pmvisions
<br />1!ARNINC: l.i lurc ro r.urc $orkcr\'.onrlt \rri{,r.oLcr i\ utrldwrul. {nn shrll \uhr$r an dnflo}tr ro.rininrlnc. ts and
<br />,ddirion !. thc c.d or conDcns.rion. d.fr+cs as p.ovidcd for rhecivil lincs up ro .rc hundEd rholsand dolhtr ($l:":ry;;E 4__
<br />lrl{l\lr\llr)\
<br />CZO
<br />7/24,//4
<br />raNSIIlrJtalt-LDlluN(i-trGEN!.r
<br />I hcrhy allirr und.r pcnahy ol pcrjtrr rh,r rhcd is a.onndcti,n Lndin8 rScNy ior rhc pcrforroncc olrhc work for which rhis Fmtil i\
<br />issucd {sm :1097. civ. c.)
<br />AffurANtoEcl,AEA.goN
<br />I hlthy xltinn u ndcr pcnohyolpcriuryonc oflhc iollowing dccloralions:
<br />Dcmnnion Pcmirs AstEsros Noiin.alion F.dcnlRcSul,ri,ns (Tillc 40. P0n6)
<br />-R.q!ircd
<br />l.ncr 6f Norifkari,n
<br />lccnityrl ihc icd.rai rcgulalions rcsddins asbcslos rcmvul at ior rpll{nblcro thh Dm]ccl
<br />-lccnily
<br />rhal I turc .cad rhisnnrl (n,rnl{n.0111rhr rlrr. rnld rrrr i\.f'rr.r I
<br />ordim.ces md Stilc tius rclllin8ft)in8..n(ruction. dr*l hcr.byaurhtrizc rc[trcr.llr
<br />nhovc nr iotud ln,lr.ny Inr ins
<br />Applic.nl o. Agcnl Signnlurc
<br />2*q: *,*-t*-*
<br />usB roofrply wirh rll Ciryand Counl,'.:::"'7u,-"-"',-
<br />Site-Work
<br />Underoround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Founlains
<br />Signs (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Bouqh
<br />Ceilings (T-Bar Rouqh)
<br />Ivleler Release
<br />Rough
<br />Service [V]eter
<br />FINAL He8//(I ry'.xyXt bj >7
<br />Notes Remarks Etc.
<br />Transformers
<br />OWNER BUILDEI DELCNRATION
<br />I hcrcby amnn u.dcrycnally of lcrjury rhar I am dcdrr tmm rhc Conrrd.i.s Lic.n€ tjw for lhc ,oltosina rctr{on (sDc.70rl.5
<br />Businc$ ad Prcfesion Codc): Any Cny or Cou.ly whi.h rcqun ! r pcnnil to onrlrucl. olrs. impelc. dcmolish or E|nt any
<br />stucrur. lrhl b ns issnoftc..ho rcluircs lhc lplliconl for such,Ennir b fib,sisn.d isrcdnr !h, h.orshc is liene{i p!F!a.r
<br />ro the pmvhions of rtE Conlrs.rois Li..ns.d Ije (chrprcr 9. Comrcins wilt Secrion 7filo or Divkion I ofttr Businc$ rn{l
<br />Porcssio.s c&lc) or thol h.orshc is cxcmpt lhcrcfromrnd thc blsis for rhc illcscdcrcmfln,n A.y violarion ofsccrioo 70:l1.5 by.ny
<br />{mlic.nr ibr 0 pcnni slhjErs rhc uoplicrnltor.ivilrenahydriorm..thMfivchundreddollur(5500).
<br />l. 0c owifi or rhc po,rny. or my cmplorrcs with wo8cs .s lhcir $k onpcnsar ioo- uill d. rtr wdl tnd lhc (utE is mr
<br />inrc.di or .fi.rcd for slc (Sa.7O14. Btrsincs lnd PDfersion\ Cod€: Trt Conttdols Lacnc L.w docs mr 'pply ro o*Nr .r
<br />rhc PIbp.ny whr boilds ur in!rcB th.N., an who des irch woll hinscllor hc'slfor rhmu8h hk tr hcr owtr cmployccr,
<br />pnvilcd rh.r soch i'nprnknrnk m mr int.nddl or otr(rd for slc. ll horcq. ric buildiq or i,rfrohmnr is r,U wirhin onc ycJr
<br />of€omolelion- Ihc Owrcr B!il&. will harc lhc bnrdcn orlmving rhdr hc or sh did mr buirl or iq'rore ttc pbpciy for lh. tdrPs.l
<br />I he6by rfllrm undf pcmny of pcrjury lhal t,n liensd lndcr pmvision ofChaprd 9 (s'nmncitr8 wilh Scclion 7O0o) ofDivhnrn I
<br />I rl'. Bu\ine* Dnd Pn,rc.!i(,n( Cod.. ot mv lncNc n itr tull roR ug{mt
<br />7z2aaV
<br />I.n'lcr'\ AJJ'c\.
<br />II
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