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ELECTRICAL.INSPECTOH RECORD
<br />APPROVALS ID/SIG.COMMENTS OWNER BUII-DER DXLCARATION
<br />I hcrcby ar6rm undcrychohy of pcdury th.' I irn cxcnrl lmm
<br />'he
<br />C.ntEroN l-ic.n* ljw fot rh. {.lkrwine rcab (scc.70rl.5
<br />Busi.es dd Prolcsibn Codc)r Any Cny or Cox.ry which rcquirc\ 0 Frmir ro onsrud. lltcr, improvc. dcnxnirh or rcFt Iny
<br />slrucrlrc. prior lo its issunrcc. olb rcqlircs |fi. aryliitrr for suchlcrmilx, filc! sisned {s(.mnr rhar h.orsh. n liccnscd aursu.nr
<br />b rhc [dvniois ofrhc Co.(rcroas l-iftns.d tiw (Ch,nr.r 9. Conrmn.inS wilh Scclion 7Ou) of Division.] oarh. Brsinc$ ind
<br />Prord\\i.ns Codc) or rhar h.orrhc i! cxcnpl lhcrclion,nd
<br />'h.
<br />h*n for lhc trllcB(n cxcmtlion. Anyliohrionolsccrion Toll5hynny
<br />nptlic0nt ror a pcnnl subjNls lhc 0ppliclnt to !ciilr.mhyolnol nnrclhrn rivc hlndrcd dollaF ( $5fi)).
<br />_1,!sowtrc!olrhcpropcny,(nalycnlPk,ytussirhwr!c\asrhcny,h.orfnsnrio..willdorhcsork{xllhc(rudmi\ndr
<br />inrc,kL{ or.flarcd lor $lc (Sr.^ 704,1. Busincs and PmfcsiursCod. l h. Coffacrois I -iccnrc lrw do.r mr ,frjrly ro {n owncr .l
<br />rh.fmn ny who buildror i,rryi)vc. rhc' Nn. md who d€s such wnl hiNcllor hcFclforrhrcu8hhisorhcrowncmpt,yccs.
<br />proridcd rhrr such nn d$.nNrc n i,ncid.d or oficrcil i(n slc ll, lkrscv$. rl.tr hr rklma or imp(*lnEnr i! $kl wirhin,,nc )rJr
<br />ofcotrrilclion- llEOwtrcr Buikls willhlE rhc h{dcn ol prcvins ltu tu or \hc dil n.r huiu or nnpmrc rhc l)lntEny lor rhc puqtrsc oI
<br />-1.
<br />as o*rc!ofthc lnorny. rnrcrclunllyconracrins wirh liccn\cd conrrado^ k,..ni c h. l(il..! (scc.7044,Iiu{nc$
<br />a.d t\i,r6ri,n Codc lhcCo ta.r.r'sLi..nscllwd..snoranrlyrodnowncrofpropcnyshohuildsori"rprovcsrhcr.on.
<br />rtrd *ho ommds ror such pnjcls *irh ! Conr6.rons) liccnscd l,ucu.nr ro rh. ConrEctn \ Liccn{ tru)
<br />;lfTdi?H-;;*W.,,
<br />DDILIAAII)N
<br />I hcrcby.llirnrundcr pcnrlly ol'Frjury onc oilhc rbllo*irr declnrrli,,tr:
<br />I harr 0nd willm0int0in iCcrtific{lcofConsctrtlo Sclf.lnnrc f(r wor ter' comp€nsrn,n. !s F,vidcd fuhysNlion ]70ooflhc
<br />ljh, Cod.. for rhc pcrfonnrn.c ofth. *ork for shth thc p.rnrl is h\ucd
<br />-l
<br />havc and will maintanr worlcn compens ion insurarcc. rs !.qutcd h! sccrion l70o ofrht hh.t cod.,lM lhc prrformn.e {f
<br />rhc *ork lorwhichlhh nermir is iskd Myso.kcri onrpcnsrri,,n i'rurrrcc.,tridr rd0oltry nun*{!rc:
<br />Iccifyrhrrinrhcicrfonutrccofrhcworklarslrichrhisp.rnririshrucd.Isnallmlcnrployrnypcsonntdti1rtrcr
<br />$ Nro bccom {hjcd b
<br />'hc
<br />rortcr compctrsatiotr la's olC.lilonri( tr.d lgtoc rhrr ir I should hc..'m srbhcl ro lhc
<br />w.rkcr' .oorix.stri l'mvi\ions oiScclion lT0Oollhc LlEn Crnlc.l\h,ll. ft,nhwirh comrly wirh rlm* lrovisions
<br />WARNINC: F,ilurc k, $rtrrc *ork.r'.orn ns i.n drvcfllc i( uDhslul. ind shrll suhicr ,n clnlhrs ro di inrl lEnnlrics Md
<br />civil lincs up ro otu hundEd rnou\0nd dollaK ($ll[.UX])dddni.n b rhc c.( ofcon,I.n\rrnni r rFc\ ds l,rovidcd lor rhc
<br />:,: '1l,hc Lrhr Codc. inrcrc(anddlorrcy r lccs
<br />hlre
<br />.DECI,ANADON
<br />t hercb, aifirmundcr pcnulrrofpcrjuy rhar I an licn*rl und.r troli{hn orchrptcr I (comnENin! wirh SNrir,.7(xx)) orDrision ]
<br />of thc Busimsatrd Prcrc$n,ns Codc.ond nrr licene is in rullaorcc udcfi.cr.
<br />IaNSIBIT.IIIANIENDINC.{AEICI
<br />I h.Eby {ifirmund.r p..rlry olpcrjury rh tlm i. s conslrucl ion hnding escm} f.r ltc ncrfomtu. or rh. work aor which lhis Ismit h
<br />i$ucd lScc.llr7, Civ. C.)
<br />AIILII;ANLIIECLIAAUON
<br />lfu.rhy.mmundcr pcnally ofp.rjlry one otrhd rolb*in8 dcclarrri.i(i
<br />DcnFlnio. Pcirnirs.Ash.sios Noriliclrion F€derrlRceullrionr(!irlc 40. Pd6)
<br />-Rcquncd
<br />Lclrs.t N.rili.rri.n
<br />I ccniryrh rhc rrdcrdl rc(ul.riotrs rc8lrdin8 osbcsto\ rcmvrl { c nolippli.al,L r. rhn p j.cr
<br />I ccnilyrhar lhavc rcd rhtopplicarioni.d(ardhir rhcatovc ini,xn i{nr iscolftr ld$ctro..nrlywilh{llCny ndCounry
<br />odimn.cs.trd SlDrc hws rclnlfu ro buildinB rucrion,0d hcrlhy turhrnc 'cprcrnralivcs oflhn Ciryand Counrylo cnrer os,n lhc
<br />rh,v. Df,drnn'.. pm|rnylar i'trfc.ridr fu'
<br />"","7/br(t{,\pplirn l dr,\ur t Silnnlurr
<br />I'rrnrilec n.me (printr:
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq i UFER
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />Ivleter Release
<br />Rough
<br />Service lt/eler
<br />FINAL tpl4lR 1 dzz)
<br />Notes, Remarks, Etc.-l crl :
<br />DATE
<br />Translormers
<br />.ncnrc Numtrr
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