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ELECTRICAL-INSPECTOR RECORD
<br />APPHOVALS DATE COMMENTS OWNER BUII,Di]N Dt,I,C RATIoN
<br />I hcruhy ,rfinn undtr 0.nrky or F jury ihai I !m cxcqn fnrn rhc (.onrudon Liccn\c Lne lir rhc i,nb*hs rc!q,' t ftu 70l i 5 -
<br />Busincs rnd Pn,f.si,)n CGlc) Any Ciry ur Cornr, {hich r.quircs r Fnnn io condocr, rhs. in,Fov.- dcnnnh or rcIJn nrJ
<br />drucrurc. prin lo irs nxuoncc. llw rcqun s ihc orpli.Mr f(tr \uch ttnnirb filc r si8ftd { cmnr rhar tror sh. il lic.n{d lllnudrr
<br />r. rlE lmvisi.N ol rlr C.nra.ttr s L,.cnscd L2w lchalrcr g. C.nnrn.ing wirh Sccri(r 7mO of Uivirn,n .l or lh. Bu\in.\\ and
<br />Pn,f.*i,nr Cadc ) or rh neor rhc iscxenllf rh.rcftomtr rh.b.\nf rh.alk!.rlcxctrrpri.n. Aiyvi.lrrDnofSrcriotr70.115hynny
<br />apfl,.rnr r{tr r ri.rn'ir subF.r\ rh. arplicahr ro sci!ilpcmlty.lnor nrrcrhan livc hunnrcd dollu6 (S5(x))
<br />_L as owmr of rh. tmrfny. or nry cmlloles wnh s.8.s $ rhci. sl. on{rcn$rbn. will & lh. wrt ! rlrsrrxfuE h rn
<br />i.rcrricd oror.ftd r.r eh lse 7tx.r. Euii*rs rnd Prerc*i.ns Codc:118 Conrmcroir licc.r L.* d.cs mr lpply ro ano*mr of
<br />rhc popcny *h) hi6s or iqro!.s lhcE,n. arld *hr d6 skh k,rk himrclf or h.r{lr or lhmu*h hir nr h.r own enFhyecs.
<br />,'mvid.d rtul such impmEmtrls aE mr hrcnd.d n olt rcd for $lc ll h,w4s. rh. hoikiin8 or i'Il)mrmnr k $ld wirhn .nc ,tr
<br />.fconDkrirn,lhc O*mr Buikkr will havc rh. tnrrt nofprovin8 thal h. or chc dil nn hDild q intme $! pDltny ad rlE purt${ of
<br />_l-r\ $mrofrrr PniF ry. r'ndrrlu\ivclr.oDkrdins *irh liccn\cdconrrrch^k,c.n{Dcr rhc pojcd rscc 7llr1. Btr$ncs
<br />a t'rntsi'n Coic lhc Conrr!.lois l-i.ctr\c L$ d cs nor rtfly k, itruwncr olpr)ncilrwho htr,ld\ or nnrr c hca{.
<br />rtrd wh. .onta.r\ rd sx.h FnE{'r "irh rConracio(1)li..n\c! pur\utrnr h rh. Conrarntr \ Liccn* Le)
<br />-l
<br />orcrcmpl und.r SNtion
<br />uoBtrEallg)MDdsarllltt
<br />D&ILAEAIIO!
<br />I lErchy !ltun nnd$ F...rlrr.ipcUury otrc ofrhc f()lkr*n! ddclanriohs:
<br />_l hrvcarlvillMinllm. C.niff,atc ofCrnrcnrnr Sclf ln\!rc fttr$.rkcr{ (nhFnlrrion, r\ Ir{,liilcdforhySdcoon:i7{X)ofrh.
<br />tjhtrCntc. fd rhc rdfomftc of ih. *o* frr ahich rhc Fnnir n isuc
<br />I hrvclndwilltnaintain wortcrs'compcnsation iNumn.c. as r.quncd hySc.tionlTmofrhc tjbor Cod.. fitr th. pcrfdrmk. of
<br />rh. *ork lor whih lht pcrnril is isssd. nl y *ortcs' c.nrFnsarion inlurdrc...ni. and Fri.y nxnh.r,.
<br />c_*,, . tl., \€'.,,.,r C,rq[,!.)-I
<br />t4\c\Oeqa134lo c) lorlt4
<br />l..nity rhrr io rhc Frforroncc ofrh. work rirr whkh rhs Fnnit is Lsucn,l \hrll iol cqrloy iny t'.non itr rny nrnncr
<br />s $ k, h..om subj.\r tu rhe *(rk.is comrcn\arion hu\.rcllinrtria. and rrrcc rhrriIl should 1$.m hj.dhrtr
<br />*orker.ompcnqttr'npnrvisioNorSe!.tr17( orrh.ljlrrCdlc.l \hnll. rtfihwirh.on1l)ly wirhrh,$ tmvnnJh!
<br />WAI{NIN(; Frihrc rr vcurc qo'kcr\ (n lln\ ion corcrrg. i\ trnh$lul. rtr,l \hxll n,hFct xn cnpk,ycr n, (ri'ni',rlp.'uhic. rnd
<br />(ivil llrcr up k) onc huidrcd rh tr\ri(l dollnr\ lSllX).lXXD. in rl(nliririt r rlt.on ol .onr|r.nsrrnrn. drmr8r\ s\ p(irtlcd l rhr
<br />Sc.ri,r:1076.frhc L'htr(ixlc, inr.rr{iid nnortuy \ fcc\
<br />o.,.,: l?tl3ll?- appu*,r
<br />I hcfthy rlfirm rndcr penllryofpcrjtry lhrr I !n liccrr.{ undcr lr\)vhntr olCh0Dls 9 kunrrcRing yith Scclion ?(xxllolDivision:l
<br />., lh. Dusinc$.nd Pmfc$ionrCod.. !ft1my lkcns. n,n rxllnr$rnd.rNr
<br />l>lo:a116.-,
<br />o",., . , 2- I ce- \ 7 (@,*r* \a L, f2-.7
<br />(.oNstaucTloN r n\Dlltc AcENCv
<br />I hcEby 3,Irm undcr Fnalry .f perjury rh{ rh.E ii , o,tr<ocrhn kdins asency fo. rh. Ffommc of rhc snrt fo, *hi.h rhn Fmir n
<br />issu.d (Scc 1097, Civ C ).
<br />APILICANLIE(LASAITAN
<br />I hd.tyafinnud.rpcnallyof perjuryonc ol'h. n hw,ngd..ld,rhnr
<br />Dcmlirion Pcrmik.Asbcstos Nolific.riotr Fcd.ral R.Sulrhnr (Tirl. 40. Pd6)
<br />-Rquircd
<br />t llcrof Notificulirn
<br />J .cd iry rhrr rh. redfl rl rs!hri,.n\ n.llrdinF,\lEnns rcnnqolurc nntamlE,hlc h rhnImFr.
<br />flkr|n, , ** ^,o,nN ,ppr'cddn and {rtc rh,r rhc !h,ve inronerhn n.6tud I dsre ro ohpl, }irh,lr ciry ind cou ry
<br />i)(lrDrtr(.\ rtrd SrJrc Ijs\ lrriiE h hrikln,! .on{tu.1 auhorn .cpmcnrdivcsolrhhCntDndCou.ryr,rnrnxr,nrtr
<br />rhtrr nf, trri{nul pfl )I{ny l(tr in\Fcri,n,
<br />,\nDlirxnr {r/tArnr Si*nntu
<br />rz1 e(Ar,^
<br />i2-r4-t?
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />-Signs (monument)
<br />Llfe Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondin g/Grounding/UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipmenl
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilin gs (Hard & Soflit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />Rou h ./r> 9*t La*&
<br />Service [/eter
<br />FINAL /k /lx 5.wlL I *nt /-A
<br />Notes Remarks, Etc.I
<br />+
<br />ID/SIG.
<br />Site-Work
<br />[\4eter Release
<br />tt'
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