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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDER DELCARATION
<br />I h6e6y armr und€r p€.flhy of p.rjury rhar I d €x.mpl fre{ rhc Coflra.lou Lic.N t w ior lh€ followins rcason (Sc.703 L5
<br />Busin6s and Prof6Fn Cod.): Any Ciry or Cou y wnich rqluns a Fmh to conslrucl. ah6, impmv., &rolish or Epan e,
<br />situdre For lo its i$uecc, also rcqut6lhc applicsl for such Fmn to 6k a signcd sdmdt fial hc or slE b lic€N.d pmuml
<br />Io rhc provisioE ollhc Co ,acbis l-ic.ned Law (Chaptd 9. Co,m.ncing with S{lion TOOO oi Divisioi I ol$. Bc'ic$ ;d
<br />holcsions Codc) oi dal hc or sh. is.x.mpt lhftarom ed rh. bdsis ior th. allcs.d 4dplio. Anylioblionofs€tion70:ll5 byMy
<br />applicanr lor a p.m subjdtslh. appli.&rroacivilp.nalyoanornor.lhsfiv.hu.dr.ddolld($500)
<br />I. 6 omd oflh. pmp€ny, or ny cnplo,6 uirh vas6 6 thcir $lc comFns.rion. will .lo th€ sork ad thc slru.rE it nol
<br />intad.d or oilscd lor el€ (Sa 70{4, Bsind dd Pol*ioG Cod. 'rhc contacbls Liccffi t w do6 not 6pply lo & ornd ol
<br />th.ntupdy who hril& or inpiovBlh@,! dd who do6 schw hnns.lf or hmcllor thrcush his or hd o$'n.nploy.6,
<br />provid.d thal su.h inpreEnols e mt inlq'dcd or o,Isrd for eL lf, howwd, $. bqildins or inprcvmdt is eld wnhin onc ysi
<br />ofcon'pldion, lnc Owrcr BuildE will hav€ lhc htrdm olprolins $d hc or stc did nor buikl or inprcv. rhe pmpory loi dE Frpoc oa
<br />I, s ownd ofrhc prcDgrx d .rclsivcly .o r&riu wirh lic6Md conha.lou lo coNltucl lhe pmj..l (Se. 7044, BBin6
<br />atd fiobsion Codc: Th. Conr.croas licm. tl* do6 nol apply ro m o*os ofpropslywho builds or inprolcs rhcr6..
<br />a.d who co ra.ts fo! such projdrs witn s Conlr.cro(s) licaMd puB@t ro rhe Co r.doas Li.@ bw),
<br />I @.r.mpt udd Sdrio. .B & l.C.lorlhGrdon
<br />-
<br />Onner:-, tvoaaE8icoMt{x,tarx)N
<br />DECIABAIIA!
<br />I n€rcby lolnn undcr pemltyofpdjulyoneoflh€ fouowins d$lrario6r
<br />I har. ed vil Dai,rain a Cc.rifical. oICoMI to SclfJNur€ lor erl6 comp.6arion,a plvidol for byS.ction 3700 oathc
<br />t bor Cod€, for fi€ pdtonmcc of lh€ work lor vhich lh€ pani is asucd
<br />\- I h.ve and \ ,ll manlam tr.,lo y comp.Bar 'ol '6r' e... s r.qLr.d by s(riotr
<br />rll. uort Io, *hrhrhBffi B su€d M\ *ort6'comN'
<br />,*- ,t/,-rJ P.'ol *. ]
<br />1700 of thc trbor Codc, for lh. p6foll@c ol
<br />N-**, ?6 uEc-Ae b bCz-
<br />-l
<br />c€1iry rhrt i. rh. pdao,mhc. oflh. work lor whichlhis p.rmil is isucd. I shsllnol mployany p!e. i. a.y nmM
<br />$ B to bcomc subjct ro thc work6' compqBar ion l.ws olcalilond od agc lhd if I stould beomc subjct to lh.
<br />worl6' comp@rion povisioN oas61ion 1700 ol rh. t bor Code. I siEll. lonhpilh comply s ilh lho$ povirioc.
<br />W RNINC Failurc ro sr. vortcB
<br />.ivil fmd up ro one hundEn thoMd
<br />Sdri.n 10?6 oarh.lrnrC.da inrered
<br />conpaEation covmsc is unlaqtul. d shall subjrt & @ploF to riniml pouhi6 dd
<br />doll6lll00.000). in addirion ro rh. cost olloopc@rion, dm.*6 s povid.d lor ln
<br />z2
<br />I hcr.by .innn und6 pmahyolpc{uryrhar I
<br />Dlicr.AMuo!
<br />undn prolision of Chap!6 I (.onmocins wnh sdio. 7000) ol Division l
<br />ol ln. arsinss md Poa*ioB Code, dd my licme t nr lull fotc d €ilel
<br />/o 38371
<br />I hcrcby a,Irm undcr p6ahy of p.dury that rhEc ia a.onnrucjo! lddin!.sm.y for th. pdfome.c ofthesork lor
<br />"hich
<br />lhis pqm n
<br />isu.d (Sa 1097, Civ. C.).
<br />GDdq s Ndc
<br />-ATTIISANLDTCI.ABAIIO!
<br />I lEt y arEn urdd Fnaky of psjury orc of llE followins delririo.s:
<br />Dc'nolition Pcdils-A.bdos Notiioriod Fcd.rll RcSulations (Till. 40, Pa16)
<br />--Rcqun d klta of Noriicdion
<br />I cGlify that rhc feddal rc8ulzrioN r.sddifls sb6tos rfloral *c nor applicablc ro this projal.
<br />Ir..riryrrr.r r\-",#rti. applicario. a.d$ar.ta! thc abov. inaomation is corcd.I asr6to @mplysih all cily d co,nry
<br />o.dinancB atrd Srd.Inrs rcLtins Io b{ildins coNtruclion, ald h.rcby.u(hotuc r.I6entarivcs ofthis Cilysd Counlylo €ntq upon lh.
<br />ibovc motioned p.op.(y tor iBpcclion
<br />ippli.rnl or Ag€nl'Sign{tu rer. - f
<br />/&tta
<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 />Communications Cable
<br />Building
<br />Under Slab / Floor _-4
<br />Bonding / Grounding / UFER j-?'244 |balac'o ikO
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rough
<br />Ceilings (T-Bar Rough)
<br />Ir4qter Re!g;1se .lzdoal {, u(4uc t /.'6.4e lwr72 r ou
<br />Rough // gDt:t //f,ttt,(r)/) ///(.
<br />Service Meter {
<br />FINAL ".3.iw
<br />(be/fuo z t''d
<br />Notes, Remarks, Etc
<br />Rev.0B-07-2015
<br />4""*.a,*,, i\
<br />,('/<o /z "
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