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ELECTRICAL-INSPECTOR RECORO <br />tD/stG.COMMENTS OWNI'R BT]ILDER D!iI,CARATIoN <br />I hcrchy amrm und6 poalty of rajury lhal I m clcmpl nom lnc C.nk..io6' Lics. Las tor thc follou.s r@t (s< 70.11 5 <br />lrusin6s and lrolsion Cd.): Any Ciry or Coumr \rhi.h rcqtrn* a ldnil lo cotrnrucl. alr6. inFovc, d.moliih ot rPon my <br />strucruq Inor ro i's i$udcc. ale r.quns rh. at'pli., aor su.h pd it io fil. a sised slaldor rhd hc or sh. i! licard pusuan <br />ro rhc pmrisions ol rhc Conrractois l.ic.ni.d t!* (Chaflr L Conm.n.in! $ilh Sclion 7000 of Division I oarh. B0.iRs &d <br />PmrBsions Cod.)or rhar h. or rh. i!.r.mpl Ihd.nom md llE h6is tor lhc allcscd.roption ny viol.rionoasenb. T0ll 5 by snt <br />appli.rniaorapmilsubjEtsthc.pplicanlloacnilrEnaltyofootmor.thdnr.hund.ddollrs(1500). <br />l. c 0*16 olrh.prop.ny, or myanrlDr.6 $irh s.!6 s thcn etco,npensarion. \ill dit ih. qort dd ih. siruclw is mt <br />inrd,:Ld or ofid.d tu slc (S6.?L\1.1. litrsios md Prot6sioN Cod. I h. conkerois Lic.m. fas do6 nol lpply tu d oNni of <br />rh. troFry rvho hril&or impio\6 rhd6n. ind who dc arh \o* tirnscllor hsElfor rhNu8h hB or hd own olplorcB. <br />provid.d rhar such imFovfft &. Nr i oddl or otrftd for sl. lf. ho{ -6. rhc hildin! or in{iov@r G $ld tr irhin on. }a <br />of conpLlion. lhc (hrno Builds rv,ll hat lh. hnda orrmrins (h, h. or 3h. dil nor hild or imt'!\! thc FoDsly ror th. puipok of <br />l.6osntrolth.fropcny, an.x.lusiv.ly.dnti.ri.t Nnh li..ns.dc.ntactoEro cotrsllu.l lh. Irojsl (Sd 704,1, Bustn* <br />rnd Profrslion cod. Th.contactois Lic.ns. Lawdo6 nol arpl' to anosnr.rflot nt who b{ildsornnprov.slhoFn. <br />itrd \ho coirrads ror su.h prnj.l. $ nh a conka.6(, li..ns.d puuwr to ric ('ontraclo.s I ic.G la) <br />I rn,.\ctrrl{ trndc' Sr((nr <br />D.r.r ORner: <br />UORKEfS' CONiPENSATION <br />DES,AAAIIO! <br />I hcrcby amnn unds p@lryoapajury on. ofrh. follo*in8 d(lamtions <br />I hare tud $ ill naihiain a C.nifi..r. oaconmi lo S.lf-tnsurc for ( orlrs compd$rion. s provid.d fo! by S6tion .u00 of rh. <br />libor Codc. lor rhc pdromdcr oarh. wort aor {hich rhc r.nnit b issu.d. <br />I hav. and sill mainlain sorlgc com!.car io. iNuranc.. s r.qut.d by Sdion :1700 of th. Ltbor cod., for lhc pcfomdcc ot <br />ih. sork tor vhi.h lhL p.ftir i3 isuql M, wort6' com!.6a1ion imwancc c idafdFli.,mmbam: <br />c&id \ onra 5<z,r,,r.r{ !4tu|.Lc.'- ?A'4( <br />Pohcy Numb6: / l\)Lss1:12A) b1 r.n,.!ot /o'//2 o <br />I c.difyrh.r inlhcpafonnanc.olthesuk ro' \'hichthisp.mrn n issu.d.l sh.llnor erplor, any r4r&n r.nv mann <br />so as to bccomc subjEr x' rh. r.*dc conllderion l.ss oi Caliiomla. and asr.c lhal ir I shotrld h..omc suhjct lo lh."t <br />w.L6 co'npGrtion pbvtnrmofSdtnrn lr00 oIthc titn Codc.I shrll,fndh{irhco <br />\rARNlN(; lia'ltrrc nr *(re *orkcr' r.'nFnsrn)n tur.rr!r <br />'scilil fitrcs up ro oi€ hundr.d rhousd dollm ($100.( <br />Sdn'n 1076 ofthc l,!tx'r Codc, inted Md rtront, <br />'o7,/tr./t /_-z:-77 <br />I hseby om,n undr p.nallyofpcrjury ihar I an <br />Df,(]dAAIIOI <br />trndcr nNvkion.l( hiplr 0 (crm'nencinS \irh S.\ridr Tllu0) ofl)ntn, <br />of rheBusinss.M Pr.fesions (irdc. and ny lic.n* Ls ii iullna.eaklcfl <br />)-o192r ,rc*c t ras F <br />",," '07/21//? <br />I hd.1ry amm undd Fnnh, oi pdjury lh.l lh6€ is o onslruclhn kndinS.rm.y for Ihc pdfomm. ofrh. so.k aor trhich this Psnn h <br />issucd(sc. 1097, civ c.) <br />a-tttlcaNllEctaSlllo! <br />Ihdlh ammund( pqahy olpdjury onc olih. LllowinS d(laralionsl <br />Daholirion Pdmns-Asbdros Notifi catio. F.{tsal Rcrul,lio.s (Till. 40. P0n6} <br />Re\ruired L.tl6 of Noliicarion <br />I cdliD lh.r lhc Ldsalr€suhnrns rcEddin! .rhdtx rdno\nor.pplrcabl€lo rhirl(ri<r <br />l.6riryrhd I hav. r. rhisapplicilion dslalel in,i,nnarion is.ond l.!.eto comply uirh rll ciry.trd ( ounrt <br />odinanc6 and Slarr l-a$sr.lalii! ro hrildin\ cotr aurhoriz.rqv6dtdn.s oflhis Cily and colnlr ro drLr upon lhc <br />at{\e nr$l,one(l p'rpeny r({ <br />ADplicinl or '1gcnl SiEmlu <br />.,1 ia^ <br />e"/Zlll <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communicalions Cable <br />Building <br />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit)/r\ <br />Walls (Rough)7"1t-t\\"vw <br />Ceilings (Hard & Soffit Rouoh <br />"-71-l\s.\fl+d <br />Ceilings (T-Bar Rouoh) <br />Meter Release <br />Rough <br />Service Meter <br />Y-zs-t\ <br />Notes, Remarks, Etc V <br />APPROVALS DATE <br />h..\ <br />v,ul1[\FINAL <br />.2----: <br />Z