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ICAL-INSPECTOR RECORD
<br />APPROVALS ID/SIG.-CWMENTS
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Lioht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Lile Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Buildinq
<br />Under Slab / Floor )
<br />Bondinq / Groundinq / UFER ,/
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinos (Hard & Solfit Rouqh
<br />Ceilings (T-Bar Rouqh)
<br />l\/eter Release I
<br />7
<br />Rough \
<br />Service Meter r a\
<br />FINAL ,/4{fi-t \Dlrrh /d\
<br />Notes, Remarks, Etc.I
<br />{}WNSR BI JII-DEN DEII]ARAfIoN
<br />I lErcb, nrirn xnd.r F6ah, ot pcrjury thlt I m cxcnfl tmm lhc C.nrero^ Lic..* tjw for rh. folhwins .casn (s.c 701 I 5
<br />Busincss md Pmlcssion Codc): Any Cny or Counry shich r.quncs r Flnlir io consltocr. alrq, inrrovc. d.mlish or Eloit uny
<br />\rrucruE,,,ior ro irs hru,k .,l$ rcquircsrh. amlica for suchpcmilro fika sigNd srarcmnt lhal tror shc k licen*d poruan
<br />to lhc povkions ofrhc Conr!rcroir Liccn\cd U{ (Ch,fl.r 9. Commming *ith Seclion 7000 or Dir(ion I otlhc Busincss and
<br />Pmfcssions Codc) or ihdl lr or thc n crcnpr lhcrcfron lnd lh. bsis for thc alkgcd cicoprion. Any viol.rion otScdion 70:]l 5 6y an,
<br />amli.a.( lb, a p.mit subjels rhc applicrnl ro rcivilpcnrllyolno! mrcrhan nrc hudrcd dollus(3500).
<br />-1,
<br />!s o*mr of lhc pmpcny, or
<br />'hy
<br />cmplortcs wilh w.Bcs .s lhct slc comt'cniorion. will d. tl* udk nrhc auture h nn
<br />inrcfli.d.ror.r.drorelc(Ss?04,1-Susitr.sundProrcssioasCodcThcContdorsLiccnsLIwdocsnorlPplyi{,anowN.of
<br />rh€ lmpcd, who iD ds or i,rp.Ths rtEb.. ,ild *tu dds skh wot{ hnD$ ll or ncrcll'or rhoueh hir or hf .wn cn9loyccs-
<br />piovidcd rh,r s!.h iq)n'vcm.rs uc trol inlcdcd or oarml for slc lt ho*dr. rrt builti.S or itqnoKm.t k sld wilhin orc FD
<br />of conpLrii,,! rhc O{er Builds will haw tht hrd.n ol pmvinS lhal hc or shc dd nor buill or in{rort $. ,mrEly fo, rtr puq-Y ot
<br />l.dro*n.r.rthcptu!.ny.amcxclusivclyconlrrcrinsNililiccn\.dc.nta.romro.o$lru.rilEpmicl(Scc?Or4.Bu\i,'cs
<br />atu ProtxsionCodc: The Conr,ci(r's Li..nsc hw @snorlpplylosnowncroipropcnywhobxildsoiinptov.slhcrcon.
<br />and who co m.N tor such pmtcds wilh a Conlldo(s) liccn\ed l[^ud ro rhc C.nlradols Licc,se L!$)
<br />I rmrrcmpr rndcr Sccrtr .u &l'C l,trrharc vnr
<br />D.r.: Owner:wotxFls' c'ompruslrrrw
<br />DECLAAAIIAN
<br />I hcrcby nflirm undcr rnalryofpcrjuryore or rhc followinA d(lmrbnsl
<br />I hrved will Ninrlin ! Ccn irtsrc .r Con*.r ro sdlrlnrur. rn sorkcr' comltcnsation. as pmvilcd ru by s*tion 37Oo ol Ihc
<br />I-ah, G c, rrtr rhc prrLlmne oilhe work nn wni.h rhc rcmn n i\sucd
<br />-,hrvcondsillnuinrrinworkcrJconJrns,rioninsuntuc.0srcquncdbySNlion:lT00orrhcLtrhorcodc,forlh€pc.tonmmcofrhhp.rmiris i\sucd. Myworkcrs .onD(nsrlbn irsurnnce.nricr xlpli.ynxn$.r drc:
<br />Cr^r^srd
<br />v.t c 1 fl)zi/zorB
<br />-l
<br />ccnili rhar h rtu p(rt ntuncc orrhc wo* ror *hich rhis F.nrn h hsucn- I rll nor cmploy rny l.rsn if, 0n] nronrcr
<br />$ At,h.conrsubrLrrrorhcwo cs' con!r.!s!t io n lats ofcllifunir, Md agEc rhar ill should hccoE ruhjcci ro rh.
<br />workcri ..nD.nsrr io. t'ovnions of Scd ion :l?00 oI lhe I rbor Codc. I nhlll ndhwilh $mply * ilh tho$ Pmvision\
<br />WARNING liilurc b {crrc *ork r(..nllrnqrn,n.ivcruc rr unhrfu| $d shrll $hjccr m cn[k,ycr t, silnim] P.rohi.\ and
<br />.ivil linc\ uIr)onc hundrrd rh.usamldolh* (Sl([).(rX]). ir rddirion t' rh. cnd ofconrF (nrion, dr. Acs r\ Irnrlidcd nr ih.
<br />n 1076ofrhc ltrlxn C,rlc, inrcrc( d.d,xomy's fccs
<br />Appll@l:
<br />ucrNsltlcllNr&rgl(x
<br />DECI.dEAIION
<br />z7v3 y 9Jrn""*.,-" C-lo Vo",," n,"*,
<br />f*," tP1zt, 8)"",."(' B. -t Lttt E le ttn'rc^ |
<br />CANIiIBIJI:DANTEIDIIIj.&CENCT
<br />I hcrcby atnm und.r pcn,hy of pcrjury rhor thcrc n a anslruction lcnding qcncy rd rh. DcrfotmRrc ol lhe work fot whi.h rhis Isnir is
<br />issuc<l (Scc.l{r7, Civ. C ).
<br />APPI ICANT DECINRA'I'ION
<br />I tLrrt'y dlm undcr pcnrlryorFrjur!.nc ollh.lollowin8 dcclomlions
<br />Dcnrlirion Pcrmils'Asbcnos Norifi carinn F.dfial R.Eulnrions (Tirlc'10. PM6)
<br />-Rcquncd
<br />Lclrc. ol NorirKdi.tr
<br />I cdrifyrhar rh. L{cral Rgulltions rcsadinE ashcstos rcmul ue nor rmli.$L l. lhis pmlccl
<br />I.dfyrharIhavca.drhhonplicrli()naBlslarcrhdrhcahrcinf(m ion i\ conNr I a3.e ro s,mpl, sirh all Cir y .nd Couflly
<br />o'dinirGrtrdsh cbssrclnlinstohuildirgcon(ruclion-udn.rcbyaurhori2.r.flcscnlarivcsoilhisCirya Counryro.trrcruln.rh.
<br />nrcnrnrned pop.dy for inrpccrion ru
<br />",** n*-r"*",r",ot,Qf,,,4
<br />B-tan,S, _bt4A ,
<br />'t l7l zotl
<br />I II
<br />DATE
<br />Communications Cable
<br />ta
<br />1 I l't/tvx
<br />I hcrcby aflinnundcr pcnalty oI ri.rju,r rhat I an licn$d xtulr prcvision ofClutls 9(conrmncing {nh Selion ?$0) oI Dilnion:l
<br />of rh. Burincss and Pof.$ions Codc, and my license h in flll f(Kt ard .ffccr.
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