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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Founlains
<br />Siqns (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bondinq / Groundino / 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 />Ceilinqs (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rough)
<br />Rough
<br />Service [\/eter
<br />FINAL *,lY/ r{
<br />Notes, Remarks, Etc tl (-a
<br />OWNER DUILDER DELCARATTON
<br />I hcrcl') !f6rm undc, r4nalry (,r p{rjur, th,! I m .x.mpl Itun 'ic Conto.'oE Li.cns tiw for lhc followins rclv,n (sft 70:l I t
<br />Bu\in.ss and Pn,fcNion cod.): Atry Ciry or Counry which rcquircs o Fnnir ro on\rtucr. alrq. improlc, d.nmlNh or Epan .nt
<br />(ructurc, Drin ro ils is.uMce. Bh. rcquncs rhc!{,plicanr ror slchFni r. nh a sign.d tutmnt lhal lrorshc is lians.n pu6uMr
<br />ro rhc pmvsotrs ofrhc Conrroclols Liccnscd ljw (Chaflcr 9. Commrcins eirh Sccrnr 7000 of Division I ofthc Busincss snd
<br />Profcsions Codc) or lhut lE o, shc n crcry,r rhcrcliom a.d rhc hsis for Ihc lllcscd cicnl'in n. Any riolmion of S(tbn 701 I 5 by lny
<br />opplican ora !.rnrir subjsrsthc applicut ro !civilFnrhyoftur B)re rhrn fik hunrlr.d dolltrs ($5m)
<br />-1.11owncro,rhcrn,Fny,{rmycnplo}ccsqilhRrScsdslhcirn
<br />conrpcnsalion. willdo rhc No srxlrhitur@nmr
<br />n cndcd or oficrcd ior elc (Sa 7Lr.rl. Busincs md Profcssnrn\ Cdc Thc conructtr\ Li.cns ljw dmr nor apply b !n .wn.r of
<br />rhc Db,cdy whi toihs o, imlmws rbcEn. snd who dm such NoIt hnns(lfor hcrulf o. thmulh hh or h.r o*n.6Ployc.s.
<br />ptuvidcd rhar such i,httrovcmnls e mr i cnded or ofcr$ t'or st. la ho*vcr. rh. hxiUing or inlhvcrEnr is sld within nrc )eu
<br />of.onplcrhn. rh Owrcr Bliu.r sill hlw rhc h{ir.i or proli.g rhxr lt or \hc dil trol huik or inpmrc dc Impcny for rhe tqbr ot
<br />_l- rsowtrcrolrhc pn,p.ny. rflcr.hsivclyc.nra.rnrg w[h li..nscdcotrractorb.on\lrucr thc pmjc.r lsd 7(}1-1. BustrEss
<br />ond Pnii$rnCodc:rhcCorrrd.rolsl,iccnscl"awdocsnoropplylomowncrofptuncnyqhobrildsorinrprovcsricrcoi.
<br />ond who conrncrriors .h a,(,jr.N wirh. Contn ron,Ii..nscd lu$u0nl iotheCo nctor's Liccn$ bw)
<br />-l
<br />rmcxcmnrundrr Sccrion .B & l'C. f,rrhir rcr$r
<br />]1()atrE&tlaut[Nsarll)!
<br />DECLAXAI()!
<br />I ncrcl,y ulrtnrxndcr pcnalrrof tdjuryom.rrhc rolliwin8 dNlai nnrl
<br />-l
<br />hrvc Ml wil I mainrain a C.n ilEtc of c.6\cnr ro s.lf ln\urc ror *o*.B compcflsrtion. as Imvidcd t,r by sNr ion ]?m of rhc
<br />hbor Codc. for thc pc.fornuncc of rhc wort fo, shich rhc p€,m t k\!.i
<br />and will mainrrii workur{ .omlEnsrln n$urrNc. ,s rcquncd 6y Sccl bn :l?m o'lhc uhor C]l ., ror rhc,,.rlor.Encc oi
<br />r which rhnpi,nir is isu.t Myworkns conllfnsdiotr ir\ur{Nc.adcr ldlpoltynunlh.rm
<br />CA
<br />$ OD \bir+ID 2fi\b
<br />l.crlity rhd irIhc p.rlo wccolrhcs.rkn)r!hichrhisp.nnirilissucd.Ishrllnorcnrl,loyunyrcroninenymani.t
<br />v' r\ l. tronE snbjd t, rhc work.rl .ompctrs0ri.n l,*{oiC.linmi{ md lgle rhll ial should hcmm \uirF.r b rh.
<br />wortcn comrcnution pn,vhn,ni orSc.rion lTmof rh. Ijtsr Cr)dc.l tull. r'onhwirh comrly wirh rh,{ prcvisions
<br />W RNINC: Failurc lo scurc lorkcrs omp.nstion c.rcEsc i\ unlawrul, and rhdll suticr an cmploycr to oininal pc@hi.s d.d
<br />civil 6rc, up kr on. hlndr.d thousdnd dollars ($100.fixJ). in additnn to lhc co( orconlEns ion, d0N8cs !s Irolidcd lor rhe
<br />Sc.rnxr :1076 ofrh. Latrtr Cdic. inrcrcst and anorrcy\ fes
<br />. {pplionl:
<br />UCDNIED-CANIM!.IQf,DECI,AMNQN O
<br />I h€rcby amrm undq pgalr, ol,ttjury rhor I m lich*d nnnf rovisionofCh.pls 9 (cohmmins wirh sdb. TcOo) olDivisio. S
<br />of lhc Busimss and Pmfcsions Codc. and my licc.sc h in frrll lor.e rnd.llccr.
<br />D+
<br />,#as\o
<br />carlirtlJr-uatrtlNlzllcllJrlcr
<br />I hcrcby rfiinnuMcr pcmlty olI'c jury th( Ihcrc n ! ensln'dion bnditrs u!.,f,y ror rhc Pcrlornnncc ollhc wotk tn whi.h rhi{ lrnnn is
<br />nsued ISN l097.Civ C )
<br />APPI-I(IAN'] DECI ART{TION
<br />I hc,byiitmufrlcr rrnJlr,orpcrjury.m.lrhc followinAdc.lunrnnt:
<br />DcnNlirion PcirnnsAsbcios Noriiicrrbn Fedctul R+!lari.ns (-l'irlc,l(). Pun6)
<br />-Rcquncd
<br />L.rlcr ol Norincarion
<br />s Eg.,{in8.ib.sos EnDvalarc not 0p,rlt!l,h i{, rhk pdr.cr
<br />ion ard \r!re rhd rhc lhorc inli,!'narn,n i\.omr I n8re rosmpl, wnh allCnylhd (:.r t
<br />ldins con\rruciion, uxl hcrchy rurtxtrizr rdprc\cddnc( oirhh Cily and Counrr ro..rcr uF,n rh.
<br />t
<br />t\(atrx1
<br />IIIII
<br />iilIlrll
<br />Meter Release
<br />l€ndc, ' Add,c-
<br />t---f--
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