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ELECTHICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCAiATIoN
<br />I hcrcby rl'tum undcr ncnahy of pcrjury IhuI I 0m exc rfl frcm Ihc Conlrnctom Liense Lrw tor lhc iollo*in8 rcuv,! (Src 70115
<br />Busincss and Prolesion CoJc): Aiy Cily or Counl, shich rcquncs , Imnit lo con(rct. ohcr, improvc. dcnrlhh or rcFir lny
<br />idciurc. rhrlo irs is\uancc. ah. Equncs lheaptlicrnl for such temln to lile a siemd (otcmnl lhal hcorshc ir licNnscd p!^u
<br />lo Ih. pmvisnrns of lhi Conta.ror's Lic.ns.d Lrw (Chafl.r 9. C.nfur.ing with Sc.rion 70fi) .l Division I of lhc Busincs ud
<br />Profc$ions Codc)or lhar trorsfie hcxcnrfl Ihcrcliom Md
<br />'hc
<br />b$h forthcrllc8cdcxcmplion. AnyviohlionofScclion?0:ll5tyany
<br />+pli.nntr(trrr.mirsxbjc.tsrhc,ppli.rmbrcivilpcmlryofn6tnbrcrh,nnvchondr.ddollnrs(!500)
<br />l- "s owncr olrhc pmpcny. o. mycnpbtes *ilh *rscs as lhcn s,b conDen\ari,,tr. will.k' rhc *uk lnd lhe {turm n B
<br />inrcMcd or olfcicd fn slc ( 5(.70*1. Busincs nnd Ptufcsions Cod. 'Ih. Cotuxcttr 1 Li.. \. lju docs nor amly ro fl oRnc. of
<br />rh. r,nipcny who hoilds.r iDrmvcs rhcmn..nd *ho dc su.h wd( hnnsclror hssclr.r limu8h hk.r hcr own cnrloyes.
<br />provid.d rh sxch inrpnr*nEnk m nor inrcnded or.ficrcJ l'or {'lc ll ho*cwi rhc ttr'ildiru or inprovcmm is qrd sirhin ncJr:r
<br />olcoqrtri,n. rtE O*rcr Buildcr sill h0vc lhc bordcn olr{vinf thot hc or slr did frn buik,.r ilr{'rolc rhc nmrcny lor rtf, purF)sor
<br />l.r\owncrolihLF,Jf,nv.xr.r.lu\ivclycontrcri',g$irhli.ctr{ conrr cttr\t,.o inrcr rh. ndNr(Sc. 7(ll,1.8unNs\
<br />!.{l Pn,ic\\iotr Codc lhcContr.clm r Liccnsc L3$ docs for itDlyro nnowlq ol fropcrlyuho huikl\ or imrrovc\ rhcrcon-
<br />rnd *ho conrmcr\lnrslchpn,jccrssirha Conrrlc!,nn llccnEd purumr hrhcConrrkn \ Lirisd l-rs)
<br />I rmcrn,pr utrd.r Scdl
<br />8!1D:1\<6
<br />I hccbyilitnrundcr lE.rllr.f psjuryonc of thc r.lk
<br />_l hrvc ond w ill m.intain worieB conEnsarion insummc. rs rcquncd hy Sariotr ]Tm of thc tj$or Code. for lhc 0saortucc of
<br />lh. work lbr which tht pcrmil is LrsEL M, works conD.nsdion insur N.mi.r a lolicy nuni'cr rc:
<br />Ic.nifyrhrrinrhcpcrfinmmc(,frlrw.rkfor*hichrhi\pcnniri\i\{rd.I\hallmrcnlPk,y ,yp.r{$innynrtrcr
<br />$ .rk,h(n r srbl.rrk, rhc uo crr .onltlctrsrri.i hssol C lilan,i( rn{lagtocrhrr ii I \h.uld h....o r srhrcd n)rlE
<br />wolkcA .onucisrri( tx,!i\ trsofSNrtr l?Ujolrlr L'htr Codc. l \hrll. la' llnv lr.onrdywirhrho*Drovisi(ins
<br />WARNINCT lrilure to rurc wortc compcnsrrnrn \uhicr !tr cnlplo)cr b mmiml lf,'Lhirs rnd
<br />conur.nslrion. drnElcs r\ rn,vnhd iq rhccivil lnrcr n! lo onc [undrcd lhousrnd dol
<br />Sccriotr]D7, ofrhc Lrbor (.nc. inrcrcn and
<br />,-,"q -Lo -tV
<br />I hcrchyJlnmu cr |[nrlryoflcrjrrr_ rltrrI rm liccn-".d i ofChafl.r 9 (.orn.ncin! wirh Sccrion ?ttxjlol'Divirion.l
<br />nf lhc Businc$ and PmltsionsCodc. und nry liccnsc is in
<br />c9NiIf,lJcUOXTEll)Ilrj-dCEnCr
<br />I h.nby rflinr und.r Fnrlry orpraurylhar rh.r h n.o.{fl.rbn lcndin! rtctr.y ror rhc r$fdrlr$c olrhc lork r'or *htn ihis rE a,i k
<br />issucd (S... :1097, Civ C.)
<br />tf,ndels N!mc:
<br />-
<br />dItl.tcaNlD[cltl3au()N
<br />I lxrtry dlim undcr pcntrlly of pcrjury onc olthc lbllo*inC dc.le.rions
<br />DcnFliiion PcirnnsAstEslos Noritlc0rion FcdcEl Rr8ullrions (Tirlc 4J. P.n6)
<br />-Rcqutcd
<br />trucroiNolificdhn
<br />-l
<br />ccnryrhot rhc tcdc,u I rc-qulorions rcrudin8 lxhenos rcmovrlffc nor 0pdicohlc ro !hi\ pd(i
<br />l.cnify rhd I hrlc rnd rhic,pplkarion axl {ard Ihar th. ab!. iifnn{rion h.omr lrtreloconrrlyqnh0llCnyandCounr}
<br />o,ti.nkclrtrd Srdrc trss 6lllin8 ro
<br />lb.vc rc rn,hcd tRrpny frtr iNnc.i
<br />rcprcrtrrdrn$ ofthis Cirynnd Counly to cnlcr upotr rhr
<br />,\DDli( nlo' \x lSixn rtr {:Z.91?
<br />Site-Work
<br />Under ground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltage
<br />flre Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab i Floor
<br />Bonding / Grounding / UFER
<br />Translormers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />lvleter Release
<br />Rough
<br />Service lvleter I
<br />FINAL n ftlN.f,\rr..^.-er.d1--zq)
<br />Notes, Remarks, Etc f l--[
<br />-lh0\cand*illtrtrirrin.Ccniaf,llcorConrnrlosclalnsurerorsork.ts.onD.nsllion.aspmvidcniorhySalion.1700olrnctjbor Codc, for rhc FrformMcc .l rh. work for whhh r hc pcroir ii irsucd
<br />l-'.cisc Cln\\ l,icc!s. Nutr$.r
<br />n8r. ( onl,acror
<br />Lcndci. Addrc-:
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