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ELECTRICAL-INSPECTOR RECOHD
<br />APPROVALS DATE IDiSIG.COMMENTS OWNER BUILDER DEI,CARATION
<br />I herchy rllird undcr pcnllry or Frjury rh,r I d .xe6g ti:on rhc ConlmbA Liccns Li* ti,r lhc lbllo-ins rcN,n (Scc 7):l l 5
<br />Br\incs ,ld Pr.fcsion Cod.)r A.y Ciry or Cbunty ehah rcqun.s a Fmn ro .-onstrur uit.. iDp.ovc. d.tulhh or rpair dy
<br />sltucrm. prid ro ils issurncc. 0ko rcquires rhc sp,,lic.nr for sch pcanil k' fik ! si8rcd srdrc@nr rh hu or sh. is liccnscd l)u6u0nr
<br />ro rhc rDvnions oa rhc Conha.tr\ Li...*d Law (Chaprur 9. ConnrminS wirh Scclion ?OOO ol Dieision I of'h. Bu\inc\r and
<br />Pmr.s\tuns C.dc)orrhar h.or shc Gcxcmo rlrrctio'nand rhcblsis iorrhc 0llcgcd excnDrion Anrlirhrn,norselirn?uil5brany
<br />apllic0nr fom I)c nil subrcck thc llpli.anr lo acivilpcn.llyofnor mrc rhnn file hunded d.lldr 1$500)
<br />-1,
<br />!\ own.rol rhc pDFny. (, m, cnlJ)lott s wirh w.gcs,r rhff qrc ompcnsrion. will do llE u'olt and rlf, nulm n nor
<br />inrcnd.{ .r orcr.d tu sh (s(.7(}44. Busimss and Prclcssions Codc: Thc Conrracroii l-icci* ti* dr{s n r q,pry lo an .Bner o!
<br />lhc pNl(ny who huilds or improbs rhB,( d sho dms su.h *r,rl himsclr.r hcscllor lhmueh hh or hct ow. cmployecr.
<br />,roridcd rh r such imtsErcds ae mt inrc .n o o0aErl for slc lt ho*crcr. rtu ioilding or im0ow,Enr i\ sH wiihin uN ,u
<br />ol.lmplcridr rh. Owrci Buildd will hrv. tr budm.lltuvir8 rh, hc or \hc did Bn hoitl or inrrrrc rhc pR,pdy Lr rhc p!q$t of
<br />l. as o*nf or rh. pmPcdy, on cxclusivcly co.trucrins $ilh lic.tr*d conlraclon rr, .o !'tu.r rh. l,{,jc' (Sc. 70q4. Busrcs
<br />and l,Dts\hnCodc: ThcConrrrdorr l.iccnr. Ijwdocl nor lprlykr rnovnn olpmp. ywho builds ornnpnvcs rh.ruon.
<br />aM Nho.onlrd.Niorsu.hImi(hwirhoCo.trro(nli.cn{dpursulnrrorhcConrracroisLicci*Ltrw).
<br />l,mdcmF uMcr Sccrio -- D. & P.C. n,rhi\ rcN,n
<br />UAArIB5]SIAIIINTAIION
<br />UICI.A.BIII()N
<br />I hcrchy afinmundcr Fndhyol Nrjuryonc otrhc nnbwirs dcclarurions
<br />I htrrr el willtrtr,idrinrCcniticalcofConscnll. Sclf.lnsun titrworkcs corycn$lion. as EovidcdrorbrSNlionlT0Oolrhc
<br />Utrr Gxie.ldr rh. Ii.rfonumc .f rh. sork L. which rhc pcrmir il islcd.
<br />I hnvcrnd willmdi,rr.in wortcrl compcnslrinn insu.ancc. !s rcquired hy sccrion l7m of$e tih.r G)dc. ior thc pcrtonuh-'u ol
<br />rh. *ulk ror*hi.hrhn pcflnir is hsucd. My sorkcn co'rycnqtion insurdncc.:rfir'd Brlhy nufrb.r m
<br />Zv-ric-1...e?
<br />rVrcotS Lgblo la-{g
<br />I c.niryrhar in rM !.rlhrmamc ofrhc *ork lor shich lhi\ pcnnir is isucd, I \hrll nur cnrlloy any Nnon ir.ny mrnmt
<br />$ $h heco"E srhJcd ro rhc wd.^ mftpcisrnnr hss orcrlinm'r. md.Brcc rhd ill s,n'ukl tecom subJcd ro rtr
<br />*orkrn comp.n\dn,n !ruvishns ufSc.r6.l70Oolrhc l,lhtr Gxlr,I drll. Lrrhwith.onDly wilh Ih,{ pfl'visnrns
<br />RNIN(; I{ilurc to scurc q,orkcr' conrpcnsari,nr corcxrsc is lnlawlul, and shall \uhrc.r an crnrlo)rr ro dirniral pcMhics ond
<br />lincs !p ro onc hundrcd rhousnd dolln (Sl(x).0q)). in lddirio rhc co( or.omp.nslliotr. damges as provided fu rhc
<br />Sc.rit/' 107r,!lrtu lohtr CrJc i,trcrc
<br />,rrr" ' ?' j- l?AL^I
<br />I hc.cbl J nDurlcr nxhyolpcrjuryrhdl3itI utrdrrF)vrn olChr s 9r()mnrcn.in! sirhSc.ri(m7lXX)) ofl)ir'\lo l
<br />of lhc Bu\irc$und Pmtcrsn,n\ Cod., rxl nry lt.ns is in tullnxe nl rfla.r
<br />, Ctc 77 lr</
<br />7-1-l ,,'rrrr^,r,,, l/ 5.411 - -5roEun
<br />Atzur:aNtr&ct A!AIo!
<br />I H,yalImru.der p€nallyoftE jlry orc oathc fouo*ins dccldalbn\:
<br />Dcmlirion Pcnnir\ A*h.sos Nolirlalbn Pcd.rol R.Bulari.nr (Tillc 40. Pd6)
<br />-Rcquncd
<br />ktr.r of Norifrdi.n
<br />I ccnilirhd Ih. ridcrrl r+uhri.n\ rcsdnrr a\trro\ rcN,rrl xrc norrrplicrblc t, rhis pnrccr
<br />_l .cnil y rhxr I htr1c rcad ihn .mli.d i.n d Htrr. rhrr rhc ,hlr inf(m l i\coiicd In8rerocomnl,wirhnllCirya Counry
<br />.rdinnn.c\ rn,l Slrrc l-a*s rclrt'! ro huikiiig.oi{d.ritnr.
<br />/.//"
<br />rhrrncrutr\.nr r$oi lhis( iryrtr(l(iunrtni otrrr. urnrrht
<br />rhorc nrrrtrEd In'ncny ir iNpccri{)n puqx)t,,\pplicml or Agenl Si(tr.lure ^*'*
<br />r'"*i,* n,,* ldno, L c59(ca H 4h,-.,,
<br />-7-!3
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Lioht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Lile Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondinq / Groundino / UFER
<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 & Soffit Rouqh
<br />Ceilings (T-Bar Bouoh)
<br />Ivleter Release
<br />Rough
<br />Service lvleter
<br />FINAL il/u/i<5\{r\
<br />Notes, Remarks, Etc
<br />-+
<br />IANSIBIJCIIOIT.LENIIDG.AIiINI}
<br />I hcrby iffi.n udc, F.!lr, or p.rjury rhar th.rc h a snsrtudbn h.dir8 l8crct ror Ihc Frl'ornurcc oi rh. wdrk r.r whih ihh trmn i!
<br />issucd (Scc. 1097, Civ. C.)
<br />Ifnd.r'. Nfl{: _
<br />Irndcis addr.(
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