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ELECTRICAL-INSPECTOR RECOFD
<br />ID/SIG.DATE
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safetv /Low Voltaqe
<br />Fire Alarm i Dampers
<br />Communications Cable
<br />Buildinq
<br />.,.1Under Slab / Floor
<br />\^.^'<r4 7yBondino / Groundinq i UFER I b 14 l\^,,
<br />Translormers vl r J \
<br />Torqueinq I
<br />&Al^f<-,lUolll e/Sub-Panels i 0 \ /\=r,Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soffit Rouoh I
<br />frw.til<>7)Ceilinqs (T-Bar Rouoh)ll
<br />I\Ieter Release U
<br />Rouoh
<br />Service [/]eter
<br />C,o?4
<br />Notes Remarks Etc.
<br />FINAL
<br />\fl\0r{It
<br />OWNER AUILDER DI'LCARATION
<br />I hcrchy aifim !od( p.nally of pcrjury rhar t m cr.mPl fmm lhc Coorr,.toE LieM Llw ror rhc folLwina Eatn (s'c 70l l '5
<br />susincs anl Profcssion C.dd) Any Ciry ot Counry *hi.h rcqlircs a Pcrmil ro snsru.r. altci imProtc .tcmfth or Epan 8ny
<br />srrucrlrc. orior ro irs issuarcc. d{ rcqun8 rh. ,pPlham lor suci pcrm h n,c a sisrcd srarcftn! th h. or \hc i\ li.ertd Purualx
<br />lo llE pmvhions of rhc Co.kr.rois LiccnEd tlw {Chapi.r 9, Commncing (ilh Section 7O0O of Divkion 3 oflic Busines and
<br />Prcfc$ions Cod.) .i rhar tr or shc h crcnDr rh.i.fmm and rhc basis tu rhc allc8cd exerynin. Anv violslion ofSccriin 70ll'5 bv anv
<br />amlicrnr f(tr d Frmi suhjcclsrhe lppli.rnr rotrcivilpcnahlolnor moerhrnivc huid!.d dollds($500).
<br />-l,
<br />ds oumr o, lhe pmtcny. ,tr my cmployccs virh *ryes a\ rhct solc conf.nsar ion. Nill do thc Bork rtl lh. slmhrc k 'rni' cn,lcrl .r olTcrd f.r sL rs(.?()44, Businc$ dd Piofcssnrns Codc: 1 h. Cont.clois Licen* tiw d@s not lplly ro ,n owEr of
<br />rhc pm!.ny who ttrilds or irnpmYcs rtuNn. and Nho dcs su.h sork hinscllo. herstlror rhrou8h his ot h.r ostrcmplovecs
<br />pr",id.d rh,r such impnJErrcnh m mr im.ndcd or oFctcn ior slc ll howcrcr. rhc huildine or irrfrercr is 5U wnhtr' nm vtr
<br />;fcoflphrioo. rh. ()wftr suiBs will h.t rtr bnnL. or provins lhlr tE o. {h. dil frn trild or inltoE rE lret'cnv fr rlf, PurlnEof
<br />;r,
<br />I)t,( t,,\R,\l t()N
<br />I hcrcby rflirm undcr ,.nahy of pcrju,y oft of lh. followi,B dslmrkrns
<br />-l
<br />harc ud will roinl.in 3 CcnifEarc orconsfl to Selfltrsurc tor work.rl conuensrio.. ri pmvilcd lor brs'crion 1?(tr orrhc
<br />rjb.r Cnlc. for lhe perfo.M.. of lhc wo* to. which th. p.mn is issucd
<br />-l
<br />havc and will tuinlain workc$ codp.osation insumncc. as rcqutcrl by Srclion 3700 6rrhc tihor Code. fo, rhc p'rfomumc or
<br />rhe wo li, shi.h rhis ,.rmil is hilcd. My*orkcs compcnerion insuruncc.r cr ud policv numbcr ue:
<br />Policy Nunrhcr:-Lrli'a\
<br />I c.dify thnr ir rhc o.rlornDn c olrhc trork i.r shich rhn Fflnir il i\{tl- I \hnll mr cnDlov lnv p.r.tr rtrv m0nmr
<br />e Nt' b..onE hJcd k, rh. workcr( conlP.nsdion hwsorcnlir'otni!. ri{tuBrcclhorifI shoukl ^*or* subjccr l!rh'
<br />woltcd.onpcosrriontn,visionsol'Scclion.l?(XlofrhctihorC(ic.tshall.fonhsirhconrPly$irhrhoelmvi\n'ns
<br />Wi\RNINC Fdlurc lo sccurc r.rkcN .onrPcns.rion corcrugc i3 !trhwful. od shall \ublccr .n cnl!]{,rrr ro dininolFmlir rnd
<br />. \iL fi'c\ rt) t, otrc hrf,lr(l ilr \rirl dolrr\ {:ll(l).1)(xr)ion. damScs .s prcvnlcd lnr rhc
<br />r076n/,hc Lnhrf',trr. ' r,u{.'nd
<br />4t418 a
<br />DECIdMII]N
<br />I lEahy rlfirnr xndd p.Mlly of Friury rhrr I am licnsn udcr pmvirion.(Chaple.9 (emmftin8 wilh Sdi6n ?dD) orDirkb' l
<br />of rh. Busimss and Pmfcstiotr{ Codc. alld my liccn* is in full fi)(. and c,f(r
<br />cQllrBllql{)N.LllDlNlilcENcv
<br />I hcEhy aifin! und.r Fmllyofpc.Jury rhar rhcrc is I connruclion knJin8.gctrcy lor rhc ncriafltuncc oIIhc *od tor which rhn Pclnir is
<br />i*r.{lrs.. lo97 Cir C I
<br />APPLiCAN'T DT'( ]I RAT'ION
<br />I lErhy aiim udo pcn.lly oaF€rjuy onc orrh. iollo*ing dccldalion\:
<br />Dcnblition Pcrnik A\hc\t,s Nolincalion rcdfi,l R.Sxhln'ns (Tilk'r0. Pdn6)
<br />RcquiEd t lrer of I'lorificaion
<br />-l
<br />c.niry lhd rhc fcdcrll (sularions rcEardins asbcnor rcmvrlta ml olPltar,k ro rhk prcjccr
<br />I.cdiiytMl I hnvc rerd rhianplicil i.trlnd shre rhar rhc .h,vc inhflMri.i t conccl I o8ra ro con{ly uilh all Cirv rnd counr}
<br />?D
<br />/Lqtr
<br />COMMENTSAPPROVALS
<br />'71 r v
<br />V. "..**, ",* ^^nr.
<br />,m c\clulkl) (onra!rms -irh lkctrEd.ont,.ro6 ro onsrdcr rtE tmirr lsec T(,r.l. susircrs
<br />J fttrrcsnn Codc: Thc Conkr.hn's Liccn\c La, doc\.or blply ro anowno orlrclcnv *ho tuilds or imrmks rheEon.
<br />6nd rh,, cnnrB.r(lursuchFFl!qirha(hnracr.ndltrcrscdpu,{,nrt.IhcCo 'a.ro' ' LKcnsc L!tr,
<br />1
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