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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDER DET-CARATIUN
<br />I hcrchy !finm undcr rEnolty oa perjnry thar I dn crcnnr r6n rh. Co ractoF Licenrc ln* for rh. rolhwirB Eabn iscc 7011.5
<br />Blsinc$ Dnn Pn,fcsio. Codc)r Any Cny or Coutrry vhi.h rcquncs ! IEnnil ro orn{ d. ahci ihFrcrc, dcmlth or r[an !n,
<br />srrucruc, pri{, k, ih irsxrncr. aho rcquircs lhc 0pplicnnl fnr such Fmir x, filcx lisn d rar.mnl lhd hcorsh. is licco(d tuBu r
<br />ro rhc n.ovirions ol rhc c{,nrrs.roil Li.c.sd kw lchrprcr 9. Conmcncins wilh Sccrion 7000 or Divhion 3 ol thc Busines and
<br />Por.\rn,ns Codc) .r rhar hcorshc hcxcm lhcrcaron and lne b&sn tu rhc rlhgcd.xenrprion. Any liolation of Sdi.n 701I 5 b, iny
<br />aDplicnnr lor rFrnril snbjrrh lhc q,tlicanr Io acililpclalryofnor fr)rrhrn nvc hun.lrd doll&s ($500)
<br />!fr-,, "-*,",'r"n ,nnr..r m, c'nrlorcc\ s h wrsc\.s rhct q'lc on,pcnslrn,n. wil!do rh. w.* ald rtE (urm ir mr' dctrdlrl or ollcrcd lu ak tSL\ 7(x4, Busdc$ antl Protcssion\ Codc: thc Conrmct, \ Lt cne bw docs nol aIPl, ro 3n ownf of
<br />rhe pmdy rho build\ or iq,oks rh.6n. dnd *ho ddr $.h srk hiNcllor hctsclfor lhrough hk or h.r own.mployccs.
<br />nrovidcd rh{ su.h impmrcmnrs e rer inrendcn or oficrcd nn salc I I how.\q. rh. hdilditrS or in{,mBEnr is sold wirhin nnc
<br />'tdor.onpkrion. rh. owmr Buikh! will h3rc ltE burdcn ofrJDvins rhd hc or {hc did nor build or impmlc rh€ I,DtEl, ior tlE PUrFc or
<br />+1. r\.wmrorrhclnlpcny, rtrrcxcluslcly.otu1.lin! wilh li.ctrscd conh rttr\ t, .oNract thc ttroi(r (Scc 7Ou. Bu\in.*
<br />dkl PNli:ssiin cudc Tn. Conr r$ror's Liccns. I nw (hN nor rl|rlt b ntr oq Nr .l lro|cn) who huild\ or i'nltuvcs rlrctcon.
<br />trtrd lho.onrad\tusu.[t]ojLrhw[hrCotri.r.lor(nliccrrscdtUr\umrbrhcG'nrn.tr'sLiccnschN)
<br />,^" . t /t /r c --*J4 8".-.^
<br />DECIIIBAIION
<br />I lErby aifi.m lodd F.ahy of pdjury onc of 6c f.l,oein8 dcclur! ions:
<br />-l
<br />havc d will tuinl.i. a ccniftare ol Consnr ro Sclf-lnslE lor *orkss s'b|).ns.rbn. as Imvidcd for by Sdrkrn 1700 ol
<br />'lELd$r Codc. for rhc tdfo@ffe or thc wo* for whah lhc Frn l is i$ucd
<br />-I
<br />hov. lnd will mrinlain workeF compcnsltion insurtrcc,6s r.qxiEd hy salion 1700 ofrh€ Llbor G)dc. ror lhc P{rformme of
<br />th. sort for which lhis pemir is isskd, My e6rkds ontp.nqri.n insunna clris ud Flicy numbcr r.
<br />ffl.cnir! rhrr in rhc pqli,nhn c orrhc work ror qhrh rhir rcrnrir n nsucd. I \h!ll nor cnlPloy dny P.^on i. ily nruner
<br />cr as r' tNonr subjLrr lo rhc workcn .ompcf\orion hss ol Calir(rnin. dd derc rhd if I sl$uld hcco,E {bj(r k,rh.
<br />w.rkcn' .otrfcns ior DFvhions ol Sdion .lT00 .a rhc Lrhnr Codc. l sh.ll, n)nh$ilh dnnPly wirh lhoY fovisiohr
<br />civil uDrs up t,.ft hrndrcd rhousa.d dollrn (Sl0u.00o). ir lddirt,n t, rhc.od.r.o dauxg.\ r\ I'o!'dcd l,n rhc
<br />/c
<br />nrcrcs lnd brcy s lss.
<br />lpptmr: E
<br />t)[(],,\R,\t ll)N
<br />I hcrcbyrft utulcr J*.ilr, ol p.Uury that I am liensn undc, prcvtn'n orchnprcr 9(.onnNncin8 *irir S6.'rion ?fiD) ol Drui\bn l
<br />of rhc Bu\ircs rnd PrnassionsCodc. ddmyliccnsc G in inllfore &l cficcr
<br />coNs'rtlk: rl{rN I trtlDIN(l A(iENCY
<br />I h.Ehy ann undcr rcnah, ol pcrjury rhar rhcrc is N .onsfl.rion lc.dirs ascncy fot rhc Ii.rro'mkc or rhc sork r'., which rhi\ IErril i\
<br />isuc iS.. :10q7. Cr C)
<br />AfILICANTDECIJSAIIA!
<br />I tlity lnim undcr pcnrhy ol l,.rjlr, otu olrhc r(rk *ins d..l!i,rions:
<br />Dc'n,lirn,n PcrfriKA\h.nos Nolificalion Fedcral R.Bulltions iTirlc40,I'M(,
<br />R.quncd l-orrrr ot N.rifi .rrtrnr
<br />-l
<br />ccni,ilhnl th. ndcral rcsu lar io na bgedhg ,sb.sros r.rmvularc mlapplicahlclo rhi\ phjecr.
<br />pfi ccniry rhd I have rcad rhis ,mlic{ion .nd srarc rhar rhc bhovc info'mlrion h.oimr.l asre rocomplysirh rllciry,nd counry
<br />.rdiMncc\ 3nd Shrc Laws r.larinl ro
<br />ibvc rfttrrirrrd proncny hr inspccl
<br />!urlNrDc rcn.c\cnrxrivcs orrhLr Ciry rtrd Counryl{) cnrrr tr| rlr
<br />PH '","t2/t/, s
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinos (Hard & Soffit Rouqh
<br />Ceilinos (T-Bar Rouoh)
<br />It/eter Release
<br />Rouqh
<br />Service lt/eter
<br />FINAL trltt ltt i4 krv4el-A >5/
<br />Notes Remarks Etc.
<br />Site-Work
<br />?/7
<br />Liccnsc Clo$:-Li.. \c Nunrh{r:
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<br />D"r. co.r.Ector:
<br />tJndd .r AdCrc$:
<br />-
<br /> It,lirr lor,\sr lSigtrilure
<br />l'€nnilc+ naN lp.ini): 9A-
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