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ELECTRICAL.INSPECTOR HECORD
<br />APPROVALS DATE COMMENTS OWNER BUII,DER DELCARATX'N
<br />I h.rcby.rirfr und.r p.nalry or pcrFry rhar I m.r.ill)l fbn rhc Conk,.tus Litas tjw for lh€ fouosins rN,n (Sc.70ll:5
<br />Busincss md Profcsion Codc): Aoy Cily o, Counly *hi.h rcqutcs a pcmil rr, .tnirru.t. slrci inprove, d..mGh o. rPan ont
<br />$ncrur., rritr k, irs hsu..., uko rcquircs lhclptlkunt ror sx.h l.rml ro filcariSncd sl .mnt lhd hcorshc n liensed ,ruFumr
<br />ro rhc pmvisions of dc Cofltr!.tols Licenrcd t w (Chs cr 9, Commmins wirh Sccrion 7m0 oa Divirion -1oflh. Bu(inc$ trnd
<br />Pr.fc$ionsCodc) orrtat hcorshc ncicr.pr rhcrcfromondrfie basn fo, rhc allcscd cxemtrion AnyvidlalionorSd6.?0ll5byan,
<br />dppli.ant lbr a p.6n snbjerg rh€ +plicdnrr.acivilFnDlryoln6r'ercrh0nhv.hx.drcddollrs(3500)
<br />-1.
<br />as oqncr oi the pop€ny. o! nry cmplrycc{ 'irh wascs as rhei nnc comp.nsartr sill do rh. w.lk ,nd (h. strluE is nol
<br />nncndcd or orcrcd f{r vl. (S( 7044, Buiim\r snd Profcssn,ns CGlc: Th C.nkr.ttr s Li.cn* tjw des mt E dy lo .n owNr oa
<br />rhc rnncny Rho builds or im[ovcs lhcmn- and who docs such w.rk himscltor hcrrcllo! rhou8h his or hcr oNn.nfk,yccs,
<br />providcd rld skh inpmvcmnk m rcr inrc.dcl or orTcEl tor qh ll howcEr. rlr huildiry or i'rfmktunr is v,Il wirhin L,N )rJr
<br />of.om0|jion,lhc Ownq Buildcr willhrrc rhc budcn ol pnvirs rtul lE or shc did mr huild or nvn,vc rhc pn,ttry ror rlE Nrrns or
<br />l. a\osicrnfrhc pmtcny. ro.r.hBiv.lycoikr.ii',s *irh li.cn\cd coftnckns ro.unnrud Ihc J,nlccl lSN. ?(}l]l- Bu$c$
<br />ond aofts\'nnCodc:rhcconirrclolsLi.ctrscljwdocstrollPplyroino$mroapnp. ywh. build\or inpn,lcs rhcrc.n.
<br />8nd who cotrrBds aor slch lnJcch wirh ! Conrncro(t liccoscd pulsunnrro rhc a,nha.tr's Lic.n* tre)
<br />-l
<br />nmcxcmpr undcr Secrio
<br />.uoatrExs.grltENsArQNDICLAXIIA!
<br />I h.r$y at,iro!ndc. p..ilry.fp.rjury oic ofrhc followinl ddcbr.rn,r:
<br />-lhavc.nd*illnsintiinnCcnificorcofConsenrloSclt-lnsurcforwortcFcompcnsarn,n,asrovidedrdbys(uonl70o.lrhcllbor Codc. for rh. Fjrformn.. ofrhc wo.k lor whi.h thc ,n,nn is isrucd.
<br />-lhlvca
<br />sillmrinrainworkcs compcnsarion insurancc. rs rcqrimd bySccrion lTfi).frh. Labor A)dc.ln Ihr Pcrli'rroEcol
<br />rhc *ork ti,r*hichlhh plrnrir i\ t{ed My*orkcA corpcn\liion nNdrmcc.rdcr rid Bn{ynu'nh.rd.- ZJrilh ftot,".'... f.yeursqtl (o
<br />pnti.y 1,nt..@p*pl".,la- t' Zo \b
<br />! kdily Ihar in rhc Frrortukr olrhc w.rk lnr which rhi\ p.rdii n issucd. I shallnot cmtloy any p.$on ir ony Bdftr
<br />s' $t' h..om sbicd b thc wor*as ompcnsltion hps oiC{liromir. lml aBrcc rhar ifl sfiould h.c.m robj.{r r.lhc
<br />wofics snr$nsalion ,mvisio.s olSecrion lTlDolthc bbor Codc.I dull.lonhwilhconlly snh lhor nnlnn,nr
<br />WARNIN(;: Fdilur. r. *.uic porkc( co.{Enerion covcngc is !nb*ful. md shall subFl an cmtk,rlr lo oininal FMlri6 and
<br />*:Y':rl;Y,qi8Y T;SdPJtJfl ry l*"* -'-
<br />- LICTMEDl;oNBAcn)a
<br />IECIJSAIIQ!
<br />I h.Nhy 0l6rmundcr pcnalty of pcrjury rha! I !m lien{t unds fmvist,n orChsrrcr9l.onmn.ing *nh selion 7m0) ofDirisiotr.l
<br />ol lh. Busincs d PturcsqionrC.d., $d my lkcn$ is h fullfom ed clfcl__-_-
<br />- cloA c46 D 60 i 4
<br />u,,", -B- l7-l8 .",,
<br />CANEIAS!:UONIENIBGIGENI:T
<br />I hcrcby aifirm undcr Fnrlly of p.rjury lhol th.E is a constdctioo kndin8 lgctrcy fo.lh. lcrfomuce 6rihc wor* ror whkh lhh r.rmil k
<br />kucd (S.c. 1097. Civ C.).
<br />ArfLtcalfD[cuxAurrN
<br />I lrR'by anirm u Mcr p.nalty of,rcrjury om of lhc follosinS dccle.tions
<br />Dctu,lirion Pcotirs rh.{oi No(iicstion F.d.r0l Rcgulrrions (TnI.40. Pd6)
<br />_Rcquircd ta(.r of Norifi ..rion
<br />-l.cnilylhrl
<br />rlt lcdcrrlrceu]rlions rcrardirs !sh!(or rcDFvillre nor $rlirrhlo i, rhi\ pnicci
<br />l.r'r lt rhd I hxv.,.i ihi\ rl,flirrri{),k)!. inln'n[iitr] i\curc.r I rlrlrroc.tr!,lysrhallCi(yrnd(iunr]
<br />ordin!Ncs rnd Srrrc I-rws rclnring t)rurlxnrc'rt1rc\ctrrdnc\.ltlnrCir) rd(,n'nr)_n).nr.rutr)nrlR
<br />lhnr nrcnli(ucd nrcrcny hr
<br />A*lk-/ (rAegr:a
<br />,i1"'Vfi- to-
<br />Site-Work
<br />Underground
<br />Li ght Standards
<br />Spas, Pool, Fountains
<br />Si gns (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / 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 (Rouqh)
<br />Ceilings (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rouqh)
<br />lVleter Release
<br />Rouqh
<br />Service lVleter
<br />FINAL 2lnlt9 //4f(D
<br />Notes, Remarks, Etc.
<br />ID/SIG.
<br />Pole Bases
<br />tJFd '.^J.ln'..
<br />tt
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