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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDER OEI-CARATION
<br />I hcrcby ulfim undcr pctrahy (n'pcrjury rhlt I an cxc,npt from lh. Crontrucl(trr Li.cnsc lrw tor th. followin8 r.0sn (S.c 7031 s
<br />ausin.ss 8rd Pofc$i,n Co<lc): Any Cily or Counly qhich rcquircs a !6n t lo constEcl. lltcr, imtrovc. d.mlish or rcnrn iny
<br />struclurc. pliorro ns ksu,n..,oho rcqunB rh.,!p]ic!nr for such pcrmil ro filc ! sisrcd n{rcm thrl lEor shc i\ liccned punu0nl
<br />ro rh. pbtisions orrhe Conrracr.as l,ten{d tj, (Choplcr 9. Comnrmin8 wirh Scclion ?fiD oi Divhion 3 oflhe Busincsr ond
<br />Pmacsiotrs Codc) or rhal h. orsh. h.x.mpr rh.6tmnatul rhc hs\is tor rhc allescd cxcnflion Anyliol ionotsccrion7011.5byrny
<br />applicrnt t a pcrn subrcc6 thc oplica.l t' rcivilFn0lryoln.r frtrcrhd fivc hutrdrcddouds($50o)
<br />l. !s owD.r of rh. potrdy. .r .ry cnDLyd.\ wnh arscs !s lhcir $lc compcN,tion- lill do thc *olk a.d lhc srMluc n mt
<br />intcndcd or oficrcd for *tu (SN.704.{. Busincss ,M Pn,f.\snnr Cnlc: Thc Contacktrk Li..n* tjw doci tor slrty k, ,n wrcr of
<br />Ihc popdy who brilds or iipr.lcs rh.dr, dd qlb des such ir)rl himrclfor bcrsclfor rhbu8h hi\ or h.r oun.mpk,ycci
<br />fi)lidcd rh{r such i'npn,vcm s m r, inrcnLd or ontEi n, sb ,( t'$vcr rhc hnildi.g o illlmEnEnr is v,lt wirhin o'ft Fr
<br />ofcoq,brion.thcOwncrBuildcrwillhrvethcl,utdcnorpmvi,Elharlrorsh.dilmrhuildorinqmrlhc,6Fnyforrn,u4rsof
<br />-l.3sowDcro,
<br />rhc ptrIrny. rNcicl$irclyco ".tl.g wirh li.c \. .otrtrn*s k, ..n{r.r rhc B)jc.r ( Scc 7(}1]l. Irusrc.\
<br />ukl l\lfssir Coll. thr Conkn&r'\ l-icenro l-ri {locs nor apnl!xr !nosrcr ofpi{)p!dysho hlild\or impft,vc\ rhcrcor,
<br />and sho co.ndstu suchpotccrs*irhrco nrki(s) lNnsrd pursurtrr blhc cb,fir.roi s I -rchsc t-re)
<br />-l
<br />ncxcnrpl utulcr Scclion-. a &PC frrrhrrci(rr
<br />Dul. Ortr€.
<br />]Y4trtrlB.r:(AUfINSA]IUN
<br />Dl:cL IIuqN
<br />I hcrcby arirm undcr !.Nlryotri.rjuryonc orrhc followins dcclr ions
<br />-l
<br />havc rd sill mitrrain a Ccnificalc of C.nE r. Scll.lnor.lor workurs onF.salion. $ pmvid.n lor by Secrion -1700 oflhc
<br />Lahtr a'Glc. for rl[ pnibirruncc of thc work fr whih rhc !.mir is i$ued
<br />I halc rtr will nuinr0in $orkcrs cotrrpcnsurion iNuroicc. rs rcqutcd hyScdnnr l7molrhc tihor Codc. li,r lhc I.rfununcc ol
<br />rhc work lor*hich rhisF.mir is i\su{d M,worle( conrp.trsolion insuran.c clricr a.d Flicy nun$.r !rc:
<br />\
<br />PolicyNunbcr: J Er,rnes: _
<br />2qccniryrhal in rhc p.rformk. orthc sork ror whi.h rhh pcrmir $ (rudd. I rhdll no! c'npk,y any r.(on in a., mrnc.
<br />s axlo bcsnrc s$jcd ro rhc workcs' compctrslliotr lows ofC.lilomi.. and 0gR lhlr if I should bccom sut (ri ro lhc*orldl c.nrlcnerinn ,novhions of Sdion .1700 of lh. bhn Codc, I shall, fonhwilh mmdy wilh lhos lmlisions
<br />\4ARNING lailurc ro wurc $orkc corlpcnst
<br />.ivil linc\ ut k, onc hundrcd rhousa ddlrtr\ ($
<br />iotr covcm8e is lnl,wful. a shall subrcr rn cnlnlorr h ri'ninal rEnalris ind
<br />ilion lo lhc cosr ol c.nrp..$rion. unrgcs a\ proeidcd lo rhc
<br />sccr(nr.1076 0lrhL l;nrnc(kl. idrrr( 'ri7h"/r(
<br />I hdchyrlllrinu dcrn MlryofF.jrry rhl I r rl.ctrwlutrJcr nol ChJpr.r9rco nkmi'r! *irh S.dKr 7(XX)) ofDiriiiotr l
<br />ol rlr Busnc\s rtrd P'ofc\\i(,n Cod.. x d n,y licctr\c i\ in
<br />7o lLr rl
<br />-- ?-?<r{)c5
<br />IO.NSItrU!:IIANIENIINCIGINCI
<br />I hcrrhya(lrn,trdcr pcnalryotFrjuryrhar rhcrc isrcon(r.rion hndiry i8cncy lor rhe Frroruncc orrhc,o rorwhi.hrhi\tlrn n
<br />is$cn (Sc..1097. Civ C.l
<br />A.TIIICAITLDECI,AMIION
<br />I H,r,rinn undcr pcnrllyofpcijury orc ofthc aollowinE d€ltr,lions:
<br />Dcmlnion PdniirsAsb.stos Nolincalion Fedcral Rcsnhtionr (Titlc 40. P{r6)
<br />Rcquircd tr{$.1 Noiifi.lriun
<br />-l
<br />ccnjlythol rhcltd.r0lrcgulJtionsEB.rding istEeos rcnrv0l arc n.rimlic$lc ro rhisrioirt
<br />l.cnify rhxr I hrvc rc(l riri appli.rr dd drrc rlln rhc lnrc inntrrorion ncomcr.l a8rer,rconDlyeirhrllCiryrtrd C.u y
<br />orthrxnr.\xtr,lSr,tr.l.'r\r.l.tri',!r)n hercby iurh.riz. rc,'rc\cnrdlrcs ol ihn Cirylnd Counryb c crrrn!rr'c
<br />lboE nrtrrn)ncd pnrt'.d, r trN
<br />,\ppli(nnl G ,\*etrl Skn.4,go L-<p!
<br />-7/-'"
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bo nding/Grounding/UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Rouoh
<br />Ceilin gs (T-Bar Rough)
<br />lt/leter Release
<br />/\
<br />Ro ugh 7-zs"tx v-W)D)
<br />Service lVleler U v
<br />K-15"t Y x.w\t)
<br />Notes, Remarks, Etc \a=
<br />FINAL &
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