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ELECTRICAL-INSPECTOR RECORD
<br />APPBOVALS DATE IDiSIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hc.cby llltm utucr pcnnhy or r"U.y rr,"r r "", """.pii-. ,r," c,.t"o*t r,**" ro* rn, rhc lnllo*ins ha.n (s*.?d.ll 5
<br />Br\ines\ d Prufc$nrn C.d.)r Any Ciry or Counry qhich rcqutc\ a pcrnrir b condfl.r. ,lrd. in{trovc. dcnmhh or rc!.n any
<br />nrucrurc. lrior ro its i\suancc. aho reqlircs Ihc sppli.anr for ruch lEnnil h filc i siarcd slolcrEnr rhal hcor \hc ir li.cn*d Nruusr
<br />n' rhc pn)visioff .fth Cotrfactols Liccnscd l-!w (Ch!!rer 9. Cor'ncncinA wilh Sccriotr 7000 ol Divhn'n ] olthc Ao\incss and
<br />PnncsionsCodc)orrhll hc orshe t.xcmpr rhcrcfi.mrnd rh. bdsi\ torficrllc8cdcxcmPlion Anrli,nrri,)n.fSNrion?0:ll5$y!try
<br />apllicanr tbr a pcnnir \ubjccrsthc imlic..r r. i .ivil !cndll! ol trot r(trcih{tr lirc hundrcd dolles (S5m).
<br />L as owncr of rh. ropcny. o ry cildoleq with sa8es ur thcir $lc conllttrerion. Bill do ltr wo ud rnc stMiEe i\
<br />incn,lcd oronarcdfors0lc(Ss?014-Blsinc(snndProfc\snNCodc1hcCo rncloas Liccnrc LIw docs nor imlt Io an oBncr or
<br />th. pmpcny *rr bilds or ihrmws rt tuh. ff*l *ho dB su.h $or* hnnsclf or hcNll or rhouph his or hcr .*n cmltoy.cs.
<br />providcJ rhd such inDmvcmnr uc mr i! cnd.d or ofcrcd lhr elc lt nowcr. rlt l,litdinS or iqrovcnrnr h sold Birhin ,,rc )trr
<br />Dfro.pkri(,( rb. O*nf Buildc will harc thc llddcn ol prclins lhal ll. .r shc did nor bxiU .r nq,bE lhc ,mFny for lhc I,urlts ot
<br />L is osftr or th. lml!.dr. lnr cktusncly conh.l inS wirh ltensd co.rdcMs t' conslrucr rhc PmJccl (SN 7(}ra. Busimss
<br />m, Pmfssbtr Code lhcConrractr'sl,icc.rcLawd..snorf,mlltuanowncroiI,()r.n,,hohlildsoridpov.sthcrcotr.
<br />rtrd who sr.,ca for such pmr.ts virn a Conhcro(sl liccnscd pur\urlr b rhc conrm.ktrt Li.cnsc Liw).
<br />I i rcxc rt, trMcr Sc.rnnr
<br />Dor. oeDerl
<br />WORl(FRS' (-1)N'PFNiATXN
<br />DICL|XAUqN
<br />I h.rcby ulltrmundcr Drn0lly of pcrjrry onc.frh. folbwing dcclrt.rions:
<br />-l
<br />havc en will minrain a Cunific,t of Con€.r to s.lf- lnsurc for {ork6i ompcnsdn 6. rs frtvid.d ro. by Scction ITID of lhe
<br />bhor Cdlc, ior lhc pstornDnce oflhc w.rt for which rh. tsnln is issucd.
<br />I harc indwill n inrrin worrcrr' conrNnsdiotr insumn c, rs rcqutcd hySccln,n-uooorrhc LfitrCodc.lbtthc Pcnnnnuncc of
<br />nnpc$drion in{trk..c cinicr dd Flic, nnnrhcr,c
<br />t)o
<br />-l.cnily
<br />ihar in rhc frftrnbNc ol rl.ir wolt l.r whrh rhN !.rnrir is i\rucJ. I \hrll nor cnrploy rtry lf,Rr in rny nunNr
<br />v)Nroh.c.mcsul,jsrrorhcNorkcficon,rcn\rrionhw\orctrlir.nri( dl8e!Ih irI \houtl hc.omsdhjd nillr
<br />sorkcis'onrpctrrllionpmvi\ion\ofScction]TmofrhctrhtrCodc.l\hill.li)dhwilhcomplywirhrlir{ltuvisrn(
<br />civil fincs uI Io onc hrnd..d rhousand
<br />:::::',-d732$
<br />). nr .dditi.n b rhc con or.omF.nsarnr drnDscs a\ !
<br />^pplicanr:
<br />D(.
<br />DICIABAII!]N
<br />I h.eby !fi.n under Fnlhy of,'.rjury thtrt I ! lienki undcr pmlhion of Chutld 9 (conmncitrg wilh Sethn 700lr) ot Division :l
<br />ol thc Busincs Md Pmfessions Codc. md my li..nk k in tull tbrc 8rn cff.ct.(lb 7Tr1lth ..,*".,8
<br />CoNSTIUCTION I ENDINC A(:FN(]Y
<br />I hrrcby iflirm und$ Fnahy ol pcrlury liol rhcrc k ! constocrt'n Lndidg agcncy tor lhc pcrformne of lhc hrt ao, whkh rhh dmil h
<br />hsucd (Ss.1097, Ci! C )
<br />ATTLICANTDECLASAIIO!
<br />I h.Ety aJIm undcr pcnaxy ofr..jury onc oarhc,blloqins dcclur0tt,o\l
<br />Dcmniri.n Pcrmni Astrr.s Norificaron Fcdcrll Rc3ularions (Tille 40, PlnO
<br />_Rcquncd ktrfi .f Norificalion
<br />l.cnilyrhI ih. ltdcrJl rcguhrion\ rcgodingrstr{o\rcnx)vrl c tur.pfli.lblc k,lhis p(!c.r
<br />6t !d,r! rr l rtr\( rc.,r rhn onntkir
<br />'nrdinrncc. lnd Srdrc L!$srcl,rinr ro hu
<br />ubov. mtrrnnrd rmpeny ior insp€dion
<br />ion ril drrc rhr lr rh,vc innr
<br />Ciry rtul cotrnrylo cnr6 ulon rhc
<br />,\pplicinl 0r Actrl SignnlurcL9 &wc
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Torqueino
<br />Sub-Panels
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Bouqh)
<br />Ceilings (Hard & Soflit Bouoh
<br />Ceilings (T-Bar Rouoh)
<br />Ir/eter Release
<br />Rouqh
<br />Service lvleter
<br />FINAL
<br />Notes, Remarks, Etc
<br />-t
<br />Translormers
<br />Air Conditioners
<br />TVARNINC ljrilurc t, vcurc eork$( .onlxrqrio,r .orcrrac is unlasful. lid shrll \ubr&r M ctrPloycr lo rinrinal pcnllri$ a d
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