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ELECTRICAL-INSPECTOH RECORD
<br />COMMENTSAPPROVALSDATEID/SIG.
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Satety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER /1-9/8 ,'/L,7/
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Solfit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />Meter Release // Q ,O Zx-z-
<br />Rouqh /'7- -Service lVleter //-,<d'Ta t/{ .--
<br />FINAL //4 /g Zz-7
<br />Notes, Remarks, Etc
<br />OWNER BUII,DER DELCAIIATIiJN
<br />, hcr.by iln.n ud.r pcMlry of lcrrury lhar l ofl cxonnt fm.r rhe Contacror' l-iens. ljw itr rh. adlr*in8 Eron (sc.70ll 5
<br />Dusin€s lod Pmfe$ion Codc): ,{., cny or cou.ry *hkh hquncs t tEmir ro consrrud, !lts, inprovc. d.tuli\h .r rur,n ony
<br />ntucr@. rtritrro iri isud.e. .ho rcquircs rhc {pltanr hr such pcrmn h fih ! si8n.d $atm.l rhar hd or shc ir liccn\cd Nronnr
<br />ro rhc povisn,s ol thc ConrEcrols Liccnrd ljw (Chaprcr 9- Co.uf,ftin8 wilh Scclion 7Ol) of Di,ision:1 otrhc Bxsirr$ and
<br />PmlcssionsCodc)orrh,r lEor\h. k cxcmpt rh.rcrtundd rho b3rn ior rhc ollcscd crcnu,lion. Anylk,larionors.dionT0ll.5byany
<br />dprri.,nr fu,pcrnir subjehrhc lrplicont ro acivilrcnalryofnor mnerhsn fivc hundrcddollrsl$Joo)
<br />-1.
<br />!s owncrolrhe rrcFny. or ny dorlort.s wirh wtrg.s ar rhcir tuh.om|rcnvrn'n. willdo rrE woll mt !h. stmturc is nol
<br />intcRleil or olTc[d for *rk (S( 70.1,1. Ausircs dnd ftofe$ions Conc: l he C{n rrck, 1 l-i.c sc tiq docs nol alplr ro an o$icr ol
<br />lh.Fmtdy wlr huilds or in{,n,vc\ rhcbn, rxl {h) di$st.h $(trk hinNlror hcrclror lhtouah hh ot hc' osn.mployccs.
<br />p'ovidcd rhrr \uch inrln)lcmnh d R i.rc'rd.d or ofcnn tbr sL ll howcrr. lhc tuiklin8 or iDrpmvrmnr is \.ld wilhin
<br />'
<br />{r yrdr
<br />olconphtidr. rhcOwncr Buiklcr will horc rhc budcn ofpDvinB rhll hc or she did nor ltrrih or inrrevc rhc Prop.ny li)r ihc Pn,Tne of
<br />L.sowncroflhctmocny..nexclusiv.lyconrracrinswirhliccn\ed.o.rh.'osrosn{rudth.ptr'jcr(S.{ 7044, suvRs
<br />rnd l\olissbn C{vlc: l'hcContr.ror's Liccnsc Laq docs nor.tplyto nnowncrollropc ywtu) huildr.r imlrorcs rhcrcon.
<br />trtrd *ho conrrBcrs for so.h pn,jeh whh ! cd ruck G) li.ctrscd lunuinr lorhc Conrrucrofs l-icc.sc Ltr*).
<br />I n ,.xr rj, ui .r Sc.ii,)
<br />Dule:_ OrDe.:
<br />wonxrn-s crrrrrpeil,rlior.r
<br />ITES,A&IIIQN
<br />I hcrcl,y arfirm nndcr Fnahyolllrturyorc oilhc lollowin8 dr.^laralioh\l
<br />-l
<br />hlvc undwill moint,in dC.nifi.ricorconsc ro Sclf-lnsurc for workc^ dn.prns n,n,ds piovidcdfor6ySccrnnlTO0oflh.
<br />htitr Codc. fn lhc pFfornunccofrhc wo* ror whichrhcrEmir is hsu.d.
<br />I hav. xn *ill mainrain wo.kcrC conDc.rarion insurorcc..s r.quiEd by S*rion l7m oilh. tjhor (ldc- lor thc p.rfonuftc of
<br />rrr *ork for which rhis pcmil is issued. Myworkcr( comNnsrlion inu.amc.ri$ Ip.ltyDunrt'$m:
<br />PolicyNumtEr-
<br />l.cdiiy ih0r in rhc lcrloirnancc olrhc work for which rht lcrdir k is$ucJ.l shall nor crDkry uny pcron i. any mmrcr
<br />s 6 lo h.conrc srbF.r b lll. work!^ .omrcnsarnr hws ofcllifuni{- snd rsc thar ifI sbuld bdom srhrccl ro rhc
<br />{b*e^'codpcnsario.p$lisiotriofsalion37(rofth.tntnrC c.I shall. ronnwirl mnpl, wirh rh.c ,mvhion\
<br />lv RNlNc l;rilrc n' $urc *nkcri conr.n tu|. d shlll \lhjccr an cmpk)tcr b onnirrl Fmhies od
<br />.i!il fifcs up lo om hundrcd I to rhe co{ oI co'npcnurn,n. dr DBcs as lrcvidcd tu rhc
<br />;:l?;'-[i'"-
<br />!I( t,,\I,\t to\
<br />t hcrcby,flirmundfi pcnrllyolrrcrjur,lhar I ur liccnsd xodcr p$visiotr orChtrltq 9 (conmencins sirh scdtun 70lo) olDivision l
<br />ot rhc Busincisdnd Pm|cs*,nsCod., &n my liccDsc is in fullfore und ciTcct
<br />o D
<br />7,/t, /t
<br />I hcrcby arfirmxnd.r Fn,lryofpcrjury lhst lhelc is a (
<br />iss cd (Sc. :l(,97, Civ. C )
<br />n'.riotr [.nd F rlrn(! t,rrhc DcrloiinrN.,,trhcsork ntr shtlrr,] \ ttnn{ i\
<br />APPI ICANTI}F(:I ARAT(TN
<br />I hctriy rmnn undcr pcnrlty oiperrury onc oflhe follo*i.E declararioit:
<br />Dcmlirion Pemits Asb.dor N.(ilr..lnn Fcdcnl Rc8ul.r ions lTnb .l0- l'un6)
<br />_Rcqrn d lrirdof Nolilicarbn
<br />'cnn,qlrr io!rt'!licrhlc ro lhi\ [,lccr
<br />,'c^/.,
<br />iion iscorel. I qrlo comPly
<br />)rn. EpEsnl3tivcs of $n Cny
<br />Drl.:
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