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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUTLDER DELCARATION
<br />I h.6by ,lftrm lBlcr pcmlry of pcrjury rhur I on cxcmpr lon lhc Conrracro6 l-ic.n* bw for rh. follo*ins rcasn (Sc.7011j
<br />Busin.s dnd Protcssi{ Codc) Any City or County lhth rcquncs u tEnir r. .{nslrud. all(. improvc, d.mlnh ot Epat an,
<br />$rucruE.priorbns nsumc, aho rcriuncs thc applic.nr lbr such pcrmn ro fi b a silncd slalcmnl thd tu or shc is liccnrd pusuanr
<br />ro rhc rovhions ol rhc Conrrn r.r's Li.c.*d bw (ChlFrcr 9, conmcmins wirh Sccrion 7m0 ol Divilion I oflh ausiness,nd
<br />Prclcsions Cod.) or rhri hcor shc hcxcmpl lhcrchommd rhcb0sh ior lhc alhsed.x.nflb AnyviolntionofS$tio.?0ll.5brany
<br />lpllico tnr ! pcrnrir subjEr\ rhc aprlicanrtuaciviltcoalrrolnornrcihdlivehundrcddouds($500)
<br />-1.
<br />$ osocrolrhc pmrEny. or my unrploFes snh *aEc\ ar rkn qrc emp.nqart,r, willdo t work..d lh. \rnxl@ is to,
<br />inrcndcd or onird ror slc (Scc 7044, ausirrrs rtrd Pmrcsi.ns Codc: Thc Contacrois l,icensc l-aw doca oor amlr ro.n ownq ol
<br />rhcpmrEny wlm builds or inDm6 rtE@n- lnd who des slcn *od( him{lfo. h.rslfor rhoulhhh ot hct owncmployccs.
<br />proridcd rhar soch iq,(,!.ft.k m to i6r.ntri or offcft] for $L lL h.w.vcr. dc h{ildiry or inrr,orcaEni i\ \okl wirhin "nc Fr
<br />oloollcrion. rhc Owncr Auitls willhar Ilt bnfrlcn.r ptuvinr rlEr h. or rh. dil mr boild or iqmw lhc IretEq ror rhc pury)e or
<br />,. rr o*mr of th. l)tupcny. anrcxclusiNl,contr lins wirh licnsd conrr..t,B k, .on{dcr rlt pojcd (Sct 701,1, Bu\in \\
<br />a tt ti\{ir C{xlc l'hc C.fua.nn s Li.cn\. Ls* d.cs mr rltlyu anowncrofrmpcnyuho huilds or imrrovcs rhticon,
<br />rnd who.otrrr.rsidsuchpmlcr{withoContncro(nliccnrcdpurunrrorhcCdnh.rufsLi.cnsubw).
<br />;""q1\iil
<br />l)l( r,,1R,\11()\
<br />I hcrcby lffirh unds pcnnlry orp.rjuryonc llhc folbwliS dc.l(dti0ns
<br />-!
<br />hrvc al{l will mirroir u Ccn ii.lrc ol C.iscnr h s.lr lisurc rm w.rktrs conrFnsalion. 0s prclidcd L. br se.rbn rT0o or rhc
<br />ljbor Codc. for
<br />'h.
<br />pcrlornENc oflhc *ork a{r wh(h rhc pcrmir is ils&d
<br />Ih,v.ddwill rinrnh work.rl compcnsarion insur.ncc..s rcAuned hySccrion:r?mnrrh. trb.rCodc. iot thc p. onMEc ol
<br />rhc sorr ror which rht Frmn ir is\u.d My workcs .o'npcnerio. insuruDcc clricI dd poli.y nu n'bd trc
<br />Poli.y Numhcr-Etptcs:
<br />--l.dniryrhrr
<br />h rh. pcnarnDncc ofrhc work lor qhich rhi\ p.rmil t hsucd. I \hallnor cnlPl.y a.t lc6.n in ony flrnncr
<br />s {st) trom subirl to Ihc sorkcr ompen{lion lass oicllil',nia. md n!ftc lh,l irl should tE onE suticcr k) rhc
<br />workcB conrpcn\ation [ovnion\ olScclion ]TlDolrhe Llhn Codc.l \h!!1. ronhsirh.um0ly wilh rhos plolnion\
<br />WARNINC: liilurc x' $urc hrL*' sqxnerion covcntc ( unl,wtul. ood shall sul,jccl !. e.lI]loy.r k' oininal Fnrllhs and
<br />civil r'itr.\ up n) onc hunnrc thot\rnd d.lli^$|(X).(XX)). iddirnn ro lhc c.( ol conr Itn\rrnn,. drtrrgr\ r\ ln,vnlcd ntr rh.
<br />Sc.ltn,.l0?(ofrhc litxn Gxlc, i crcirndar
<br />/8
<br />I hcrcby aflirnuidcr l.n.hy orrcrjurylnar I io lienEl r rmision ol Chrprcr 9 iclhm .tr! qirh Sccri.n 70(x1) of Divi\ion .l
<br />ol rhc Bu\in.s\ md P'olc\\ion\ CoJc, drl nry li.cn\. is in lulltur.. dDd cllarl
<br />D.r. ('onlroclor
<br />calsrBllguaN.LIlDAc-f,aElcr
<br />I h.toby afliim und.r Fmhyofpcqury rhlr Ihc,c h a @nsru.lion lcndins agcn y n, lhc P.rformmc oi thc work for enich rhk Pcmir ii
<br />nrucd (Sec, :lO9?. Civ.C.)
<br /> PPI I(: NT DFCI ,TR^TION
<br />I hcrchy dilmr u ndc! pcnolty orFrjury oi. or$. r.llowinS de.ld !.i\:
<br />Dcnnirion Pc.nnsAsbsror Noiiication Fcdc.rl RcBUIllionr (tnh 4J- Pan6)
<br />Rcquiad trircr ol N({ifi (rrhn
<br />I ccniry rhd I hlv. tuad rhi! lppli.rrionturlsatclhor l[c0hvc inionndion i\c.tr.d Id8rct,.on{'lysnh0llCnyondCounr,
<br />ffil hcrchylDrhorizc rcprcenrrriv.s ofrhis Ciry nd Counly lo cnrcr uF'n rhc
<br />abv. n{nrnrcd ptr,r.n! tu ir\
<br />Drt. - jl t7z/tt
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm i Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rough)
<br />Meter Release
<br />Rough -/-)( z->
<br />Service lvleter c, -LL-(a',/rfi+t,7r'{
<br />FINAL - f-16't1 lltzz
<br />Notes, Remarks, Etc
<br />Lcnncis Nrm
<br />-
<br />-lccnilyrhr[hc
<br />ledcrul rglldions rcgaii]nrB rsh.nos rctrsvdlarc rct etlicohlc h rhi\ poj.yr
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