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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE COMMENTS OWNER BUILDi]R DT'LC RA'IION
<br />I h.rcby ,rrm undcr Fnally ol lcrjury rh.r I m cxcmpi imm rhc Conka.ron Li.cnsc tiq ror lh. iolhwins rMkir ls.c mrl s
<br />Busincss snd Profc$iotr Codc): Any Cny or Coxm, which ftqutcs r Frnril ro con(ocr. allcr. inlir.v.. dcmlish or ;cFn .n,
<br />(rucr!rc. priorlo irs is\uakc, also rcquircs rhc applicdr ror suchllmit Io filca \isncd ndrcftn har hc or shc h licc.scd tlN.nr
<br />lo rhc Eovhions of ll'c Collra.loii Licrn\cd ttrw (Chrri.r 9. q,m,ftmin8 rilh Sc.rbn 70(x) of Divtion I or lhc Busirrc$ rnd
<br />Polcsion! Codc) or lhsr lJ u, shc is.r.n4l rhcrcfronr Md rhc brsh for Ihc {lkScdqcdprn'n Any viol0rionofSccrionT0:ll5 hyany
<br />rrplicidrordp.rhitsuhjetsrhcaprlic0nrto0civilpcmllyofnolmorcthsfivehtrndtddollrs(1500).
<br />l.0sowtrcroirhcpmp.ny.ornrycEpbrrcswirhwr8csNrh.irnnc.omNns$nin,silldorhc*o,rlrhcdn mi!nor
<br />inrcri.d or otTcrcd lor sle ( S( 7t)44, Busincs ,nd Pnnc$iurs Coic 1 h. Cofilcttr\ l-i.rn* Irs des nol tnrly ro an n*ncr or
<br />rhctripcny who trikh.. inrr()rc\ rhcEL snd $h dos skh w.* hnns.lfor hcrrlfor rhrcuft his or her own cnPk,yccs.
<br />tmvidcd rld nrh iqr.rnrnc m n.r intdcd or oflar.d lbr elc li howcKr, rtE hri[nE or illl(*utN t v,ld wihin onc )tr
<br />ofcorpkrnm. the Oqnf Buikig will harc tlE ttrdcn ol pmlinS lh hc or shc dil ior build .r nvmrt thc lmtdy for rhc ll{n{ ol
<br />l.asowncrorrhcpml)clly.rmcrclusivclrcodra.rins*irhlimn\cdcotrcro^to.onstruclrhcpmrc<l(Se70'14,Bu\ift5s
<br />ond h'lc$hn Cod.: lhcConkacror'sLi..trscL.wdo.sno!af!lyroMowncr.ipnrp.nyshohrildiorinprovcslhcrcon,
<br />0nd *ho o nch ld strch F)Fcrs *irh a CoorDct,(t liccnscd punud h rhc C.trk0rl.ls Liccn$ l-lwr
<br />I ofl cxcnrrl undcr Scclion
<br />!!18f,!8S:l;!lMPiNrArI()!
<br />DECLAAArcN
<br />I h.nby alfirm utrdr pcmlly of pcrjnry om orrhc rollowing ddlrarions:
<br />I hrrc ,nd will roinrain a Cdificatc ot Consnl to Scla l n{E for workdJ smFnsal ion, 6 povilcd for b, s€.rion 1700 of rhc
<br />Lf,ho, Cdlc. for rhc pdrollffi. ollhc vo* for which rfic pcrmil h issucd,
<br />I hrvc rnd will mrintiin wo*eB cohpcnsaraon inslEtuc, ar rcquircd by Sdion 3?dl of lhc Labor Codc. fot rh. pcrfomnc. of
<br />w
<br />lY
<br />a q //t c<
<br />oo
<br />I..nify(trr ir rhc Fnoflnrncc ollnc sul lar *hich rhi\ ncnnir k isucd.l shrlln.r corPloyrn, Pc6o in y trmnNr
<br />ar sro tEom $b,cd b ihc wo.k.* cotrf.n\ ion hH .f Crlilor nir. md trgrcc rhar if l nx,uld h..o r subid lo rh.
<br />lqkcrs.omncn\rliontmvnion\ofSccriotrlTlX)olrhchlinC{nlc.lshall.tunhwnhconlIlywirhthortmvi\ions
<br />WARNIN(; lailurc ri scurc $orlcr comFn\dn,n covcrugt i\ unlrslul. rtrd \hrll {lh]!cr rrl c r oy.r t, ai,niMl Pctrlh-:\ rnd
<br />cilil nncs uD ro onc hundrcd rh.usand dolLn l$10O.(xD). in dr r8c\ ar providcd tur rhcilihtr (-odr. i' rrcn r d xrktrnry \ lcc\
<br />Vrt
<br />DECLASAIIQN
<br />I hcrb, arfirm und.r p.n,hyolperjury rhll I am lienrd undcr rmvision drchdptcr 9 (comrmmiry wnh Seri,n 70m) olDiris l
<br />of lhc Busircsund Profc*ionsCodc. aM,ny li..nrc is ir lull lor.c afrl ctlccl
<br />U % ac1
<br />qG"a.
<br />ralirBlJsllaNl[Ntlltill;.ENll
<br />Ihctohyam.hund.rp.MlryolperjurylhulrhcrchacnnslrudionlcndnrSagcn.yforrhct'orrorccotrhcuortforwhichlhislctrnilis
<br />issu.d (Scc.3097. Civ C )
<br />ATTI,ICANI"DECLABA.UAN
<br />I hftU drm undcr Fnalry of pc+ry onc of th€ folloqins dcclr ionsl
<br />Dcmlnion Pcmirs AslEstos Nolifi.alion F.dcml RcSulalions (Tillc40, Prn6)
<br />-Rcqlied
<br />L.lrcr ol Nodrr.lbn
<br />-/ I sn'lyrhd rhc lc.lcr.l rc8uhthn' rgodrs a.b$loi 'cnr al s' e norrn,,lrc.l,klo thh Pmj.d
<br />-UI c.n rfy rhr! I hlvc rcld rht applk.r hn rtld {ar. Lh.r r hc 0how infornElion is coftcr I agr ro smply wilh all city and counry
<br />! ninr&c\.trtrlsrxr.1rN\ '.hr rsn) hd'll cotrnfldtrD. irkl herchyrurlDriz. r.lrc\cniarircs of rhi\ Ciry
<br />)txnr trrrri,)i.J In)pcny fttr i'NI,c.rirnr
<br />'\pplicnnl or Agrnl Sixn tuft
<br />l'(nnil( n nc lrritrtr: ,(r
<br />)i/"4k-
<br />Site-Work
<br />Underoround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm i Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER f //7tif t </llEnA-- /b\-/l" '!
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinos (Hard & Solf it Rouqh
<br />Ceilings (T-Bar Rough)
<br />Rough
<br />Service lVleter L d nltvll+-
<br />FINAL ital,r *'.11a**-ln-,/
<br />Notes, Bemarks, Etc.,.l' ' 'v-
<br />.)
<br />ID/SIG.
<br />Transformers
<br />Meter Release
<br />9--'/412- Zooato tfZ
<br />ql t/fi
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