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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE tD/stG.O1+NEi BUTLDER DELCARATION
<br />I h$cby a{firh undcr !.nalry of pcrjury rhar I ancrcmfl forn rhc Conrochr Liccns tjw l'or rh€ lollooirs r!\.n (sec70:11.5
<br />Busnrss lnd Profcssnnr Codc)r Any Cny or Counr, *hth rcquirc\ a pcmir n, ..n{rucr. dlrer. irptuvc. dc.rlish or rlEt My r
<br />drudurc. prior ro ik i$uane, aho rcquncs thc .t'plic,nl lor su.h p.rnit ro lilc r ri-qtrcd $armd rn nc or shc is licc.{rl I'Unumt
<br />lo rhc rrovhions oflh. Contn lor's t-icenrd br (L^hdprcr L Comnrftine *irh Sccrion 70OO of Division I ol thc Busincs rtrd
<br />Pnft$ions Codc ) or thor lE or shc h excmpr rhercfmn !M lhc b.sis id tnc .llcgcd cxcnrfl ion. Any violarion of Sdhn 70.1 I 5 br !n,
<br />aptlica a.r a penln sunjccri'hc amlicu ro acivilpctrrlryolnolmlcrhan fivc hlndrcddollds (5500)
<br />*1. .s ow.cr ol rhc trcFrty. rn my .nployc.s with wr8er as rhcir \,L .ompcns.rt^ will do rh. work mkl lhe sltrturc i\ ml
<br />i crdcn or olttrcn for slc (S(.70,r4, Busimss afld Profcssions Cod.: Th Contlcft, s Licctr* L.* des not .Dnly lo sn osmr of
<br />rl'c tln,lrny wl[, hlilds or ir'll,mv$ rhcNn. snd Nho docs sEh won( himsclaor hcr*ltor rhroqh hh orhcrown cn{l.yc.s,
<br />pnvidcd rhor {ch impmwrrcd( e nor ir .ndcd .r .ffcE{ f(n slc ll ho$.wr. rh. bui ill8 oi irFovciEnr is v,U wilhn .rc }tr
<br />oi omplcrion, fic Osncr Buildd will haw dE burdcn ot l,oeing rhnt hc or shc dil frn bxild or inptulc rhe lrmtdy f.r r]r !u.Fc of
<br />-1.
<br />$osncrolrhc pru|xny. ,m cr.lusivcly coftndnrt wirh lic.n\cd .onta.lds L) ( \lrud lhc F,jc.l (Scc. ?(}44.8usin$t
<br />,nd Pn'fdii,n Gdc: Ih.Conk,croasl-ic.n\cliwd.csnoilnnlyloanownerofpror.ny*hol,uildsorin,p(k\rhcr.on,
<br />and who co a.ls lot such,rotccls wirh. Cofticro(s) li.cns.d tusurtrr ro rhc ft)nt.ctof s Li.cnsc ljBI
<br />-l
<br />lnrcxcmil u crsccrmn , A & PC nr rhi\ rcrqnr
<br />Dnre: O*n€r:
<br />WORXFITS'.(iMPFNS TION
<br />!trcLA.BtrUO!
<br />I hcrcby slfinnu.dcr DcnallyolDsiuryonc of Ihe rbllowinx d..larnlhns:
<br />-,
<br />hnvc aftlwill nriot.in aCcnificnrcolConsctrrro Sclilnsuic lor $orkcs' conpensd ion. !s pnrvidcd lor bySccrt,n.l7(x)otrnc
<br />Lnhor Cddc. for rhc p.rfornrane ofrhc qo* ld whi.h rh. p.rn,ir k i1\!cd
<br />rnd $ill mainhh workcr .ompcnsalion insuftncc. as riuiEd by S4rion l7(x) ol lhc Lrbor C!de. for rhc pcrfomE oI
<br />ion insuratra cartr od Dolicy numbcr m:
<br />!4s.Jv i\ n{rd. Myworkc6 com0cnslr
<br />a
<br />fi N ., \.r cO r1,t |'ln L .r.\1
<br />-l
<br />ccnilyth rhc pcrlornDNc oirhc work i(tr *hi.h thi\ rcrmir is is{r{.1shrlltror cmpk,y any p.ron in.ny motrncr
<br />w' as lo lEonE sub]cd lo rhe roricG' comncnsal ion laws of Clhroarin. and a8e Ihal il I lhould ll. o,N suh]cd b
<br />'hc*orkcs'co pcnntrio. pmlniotrs ofScction 3?0Oofrhc Llt r C.dc. l shdll. fodhwirh conr/y wirh rnoc rrovhions
<br />cMl linds trtr b oi. hutrdrcd rhousr*l dollrs l$loo.fin). in rddnion b rhc drntrEcs rs lrovdc{ tor rhc
<br />4 ol rlr Inltn (i c. ric'cr r l nn.nry \ rr.\.L. tq.
<br />IIEIJAAAIION
<br />I hcnby afilrm undrr Fnslry of Frjury rhar Ln liencd undd rolision of Ch+r.r I (.onmkiig wirh Scdk n 70001 of Division :l
<br />ol lhc Busincs lnd Pole$ins Codc. &!d nry liccnse is i. full foR Nd cr'l!rl.
<br />3
<br />4.(r,.tq tz,-44L
<br />CONEIAUJII}IIEIIINCIqENCI
<br />I hsrcb) ufiim undc, pcnalryolFrjurylhal th.E k o conslruclion kndin8agcncyforrhctcrforromcollhc worl tor shi.h rhil lxrmil ii
<br />ksucd {S(.1097, Civ. C.).
<br />Lctrdfl ' Nam:
<br />l,ndcls Address:
<br />-l.cr(ilirhrrrhclad.fulrclulnrtr,fs rc!mt'is rsbcno\ runn)vrl rc Ni ttli(n[]c r) rhis t)niN.r
<br />H;:llllli\ll$::l1l his trl,plc{rio' xlshrcrhot r lnsr( h-rrrb {irh rllCir! ntl({)unrt
<br />lrh'\ ( irr- rrt c.unry r) rnrLr uFrtr rlr
<br />.\DDli(rnl or,\tcnl Si*natun
<br />Yort'r/ ,4r
<br />4 b./ ?"t
<br />Underoround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Salety /Low Voltaqe
<br />f!4r Alarm / Dampers
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundino i UFER
<br />Torqueing
<br />Sub-Panels
<br />Roof Top Equipment
<br />Facto ry Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinos (Hard & Solfit Rouqh
<br />Ceilings (T-Bar Rough)
<br />[/eter Release
<br />Rough
<br />Service ltrleler
<br />FINAL l0lLt-hc 5N<c(
<br />Notqs, Remarks, Etc
<br />COMMENTS
<br />I g,t t.? 61..
<br />AIPUIANLI]EITAEAIION
<br />I ll{b, nflim undcr l,..ah y of prijnry om of rh. f(rbwnr! d(lnrur ion\:
<br />Dc'mlirir)n Pcrni( Alhedos Noril_'crii{,n FcdcralRcaultrrion! l'l'itlc 40_ Prna)
<br />-Rcqlirc{l
<br />Lalcr of Norificali,,n
<br />Site-Work
<br />Communications Cable
<br />Translormers
<br />Arr Conditioners
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