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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG,COMMENTS OTYNEI BUILDER DELCARATION
<br />I lrcrcbt al6rm undn t'.mxy of pcrjury rh l m cxcmfl fmm rhc Conlrgclos Lianrc Lrw for lhc followins .cann (Scc 7011.5
<br />Businc$ and Pmicsion Codc): An, Cily or Counly which rcqutcs a pcrnrir lo consltu l. alrc. iqrrove. dcBni$ .r reldn 6ny
<br />srrucrurc, tior lo ns ksu6ncc, oho rc{tuncs rhc arpliconr lb. su.[ Irrni ro nh o sis.cd staretr rhdl lrorshc t li..ns.d puBu0nr
<br />ro lhc pmvkions ortrE C.nrmcroas Li..n$d uw (Chaprf 9, CommcminS with SNlion 7ux) of Dilhion I oflfie Blsincs lnd
<br />Pmfcssions Codc) or lh|t hc orsh. iscxcmnl rhcrcfrcD !.d lhctEsk for rhc olk8cdcxeflrflion. Any vnrblioo.fSerionT0ll.5byany
<br />,h#-ffiffi .ffid#;;;ffiffi;il:r;ffi ffi :*",",
<br />rhc r$lxny who blildc or irpmws lhc6n. dd who do( su.h w)* himr.lror hcrslfor thmu8i his or hcr ownemnk,)@s.
<br />pmvided rhar such imFmvernk m tu, inrcndcd or.ftrcn lor sk la hokrci rhe t ilding or inlh,vcnrnr h sold wirhin onc )rd
<br />ofcon lclion. tlE Owmr BuiUs *ill h!rc ltr t[r&n of rmvin8 llEl lE or nE dh ml hild or i.q,mh lnc poFl, lor th. pu4n* of
<br />;: bk ?
<br />I hcrcby lltirm undcr !.trlllyofpsjuryorc ofthc followin8 deldalio.s:
<br />I h,w ,Jld wiu minr,in n Cdif$rc or Conrm to S.lt-tnilE for worrd{ nrorens.rion. 6 J,mvidcd aor by S(l ion 3?00 of lhc
<br />ribor Codc. ior lie p€iformrc of thc *ort for ehich l,E rrcmir is issled
<br />,lh0vcrtrdvillnrirlainworkcsconDcnsorioninsunmc.osrcquircdbySccrion:1700ollhcL!$orCode,f{rrhcpofdrtuiccol
<br />l,E work for ehich lhh lcmil is nsuct. My wortcr ompcnsorion inslErce cuicr ald policy nrnhcr e:
<br />Policy Numh..-Ex0ncs
<br />--
<br />/llly'."\X'iy,r,,, * 'r'" 6'r*mtuc or'rhc wo ior*htrhrhispcrnirisissucd.lshallnorcr0rt,yaiypcroninany'n,nnct
<br />'
<br />^.
<br />l( ro t mft objNr k, rhc Nnrk6 $'nn n\Jri,m L!\ orCslir.rnia, a.d rgft rh,r ir I should hccom suhiEl ro lhc
<br />*orkc(' .onp.n$rnrn pnrvhions .l Scdion 37uJ or rhc tjbor Codc. I shall. fonhwiih .omply with rlFc lrovisiotrs .
<br />\IARNINC: Frilurc ki r.urc $orkc6 .onrptn\atn,n $krrg. '\ unhsful. x nrll \lbjccr !| c rnl(,,tr t. criniNl Fnikf,s rnd
<br />.rll ftr.\ un rr on. hnrlrc(L rhon\r rlol x^ lslrx).ixx|. m rddirr)n Ihc.oi of.ompcnslnon. d,ntr8cs {s [ovidcd lor lhc
<br />;:l-,-'ui,?{lig
<br />I hcrctry alrtrm under Il.MIty o f pcrjury lhal I om liened undcr !,mvkion olChoDtcr 9 (commrcn,s wnh Scdirn Tlxx)) otDi!i,io.:l
<br />of rh. Busiftsc ud Pofcsions Codc, .nd my li.cnsc h in tull forft and cllt.i.
<br />-Liccnsc
<br />Nunbcr:
<br />cQNsrf,lcuQNLENDMiili[Nct
<br />I h.nby rmrn undd Fnnlry of p€rjury $ur lhem h a consd.rio. IendnE decky tu thc pcrfolmre or lhc rcrk for qnich rhis pcrm h
<br />nr!.d (se :1097.ci!,c.)
<br />AITI.IIAILDECIABAII9N
<br />I hmbyofildnnndcr pnrhy orr.rjury on olrh. lollowing dehmrions:
<br />Demn ion Pe.mic Arbcsros Norilicarion Fcncrul Reslhrio"s (Tirk rl0. Pan6,
<br />-Rcqxncd
<br />bncr of Nolifi calioi
<br />ylh. hc l.dcral rcBulations rcru ins asbcslosrcnDvdtrrc trot 6pllicrhlc to rhi\pmrccr4aA
<br />'!4lj/adiry lhal I hnrc rsd this applicrrion ond stdcrhar thc atnlr inlbrmarbn ii cor(l ! asre r. 6'ryly wilh .ll City and Counly
<br />nd srarc bws El ri.ero buildinS .onqrucrn lrxlhcEbyaulhorizcrcprcs arivcsolrhhCiryandCornryrocn(cruronrif,
<br />ahrv.
<br />'mnrioncd
<br />pml.dy ntr insr.crion lullosc\.
<br />'\t't,ln nl or A[(nl Si,rnnt,'rr
<br />IP,tb k,>.* b/#ll
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm i Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFEB
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof To p Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouoh
<br />C eilings (T-Bar Rough)
<br />Meter Release
<br />Rough
<br />Service Meter
<br />FINAL ttILT,4E,:>\r#
<br />Notes, Remarks, Etc
<br />-1.,s
<br />ownd nfrhc F)Icriy..fcx.tu(ivcly.onra.ling wirh lic.trscd.onlrnckxslo connrud lhc pmjd (S.c. 7044. Buiims
<br />"trd Pmlbsion Codc: 'l nc Contactorrs Li.cnsc l-aw dtrr nor lpflyro an osncr oftrdp.dy wh. build{.r inD(ncs lh.ron,
<br />Md who conh.ts nr s.h l)l)jcds qith ! Conlmdo( s) lietrsl puruanr r{r rhc Conrrldoi s l.iccn\c l-3N)
<br />tr.n,hl \ AJJ,i$
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