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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE COMMENTS OWNIlR BUILDER DELCARATION
<br />I hcrcby olfirm lndcr pcntrll, or pcrjury thst I m cx.npr aho the Conkacrod Lidn* ljr 16r rh. f.Uowins rclsn (sc 1l:1 l 5
<br />axsinc* lrxl Pmfcssk,n Code) Any City or Counry whkh ruquncs , Fnnir ro onstud. arr.., impror, d.molhh or Epan ,ny
<br />*rudm. prkrr b irs nsuricc, dko.cqlircsltc uppliconl to such,En.il to illc o siSmd sldc,rcnl rhar hco.shc is licc.scd pu uMl
<br />i0lhc p rlGions oI tlE Conrraclols Licctrscd Ljw (chdrrfi 9. Comncming ukh s.cri.n 7@O of Divirion:l otrh. Bu\ihcss aid
<br />Pnrlcsions codc)orrhi hcorshc ndcmfl rh.,clrom ond thc basis for rhc alhBcd .xcmprio. AnyvioltrrionofS(rion70ll.5byany
<br />applic0nlior. pc.ril subiccls rhc rrpli.anr r. r.irilpxnahyolnor horcthan liyc hundrcd dolhrs(i5ul).
<br />L ns owncr ofih. pnFny, or nrycnul{,Fcs *ilh vnSes os lhcn sb.omp.trs!1i.tr. will do rh. wtrk a*ldc rnxxurc N mi
<br />inrendct or oflrcd nx eb {se.7lx,t. Busimss lnd Prcfc$ions Codc: Th. Conrra.rol \ l,iccn* Law d.cs not lpnly h !n owmr oi
<br />rhc pn,p.d, uth t{ild\ or improv.\ rhcmn. lnd who dtus smh *oA hnnsclfor hrnclf.r rhhugh hk or hcr own erntloyccr.
<br />pmvidcrl r hor su(h iinpmvcnrns ft ton inkndcd q oiIcEn for $h Il hoqcrcr. rhc hiklinB o. nryn,vcm.l h $h wirh'n o'k irr
<br />olcomphriotr. rlE Own$ Buildcr wil!htrE rhc hrdcnotlmviu rhd h. dr shc did mr h{iU or iqmk lnc 0oFny lor rhc purFc of
<br />l.,\duturorrhc pnrpcnr. ! ciclu\ivcly contdir8 wirh li.cn€d conhtuN
<br />'o
<br />co.{d.r rrE proj.d (Se 7014, 8ulift$
<br />r.x, ItDlssion codc: Thc Co.ria.h r Lic.nsc liwdoc! io! aprlyk, onowncr olr0pcrtywho buildsornqmvc! thcrcon,
<br />rnd sho s,nrrocls lbr such pnJcds wirh a Conka.l.r (s) liftn$d pohuni ii,rhcContrctr\ Ltcnr L!w)
<br />I rrcxc rU undcr Scc.oi B & l'C hrlhir rcr\otr.
<br />D.l.: - Omer:
<br />wonxr*si:iruprr,rs,lrrirr,r
<br />DEclrIBA.IIg!
<br />I hcr.hy.rfir ond.r F.olr, ofpcrj!ryorEoflts follo*in8 delr.rions:
<br />I havc md w ill roinkin a Ccnificale ol Consctrr b Scli.lnslE ror workds ohpcns,rion.!s proviil.d fd bySc.rhn 3700 orrhc
<br />tjbo, (]odc. for rhc lcdormincc ofrh. wolk ao. which rhc p.rmir n h\md
<br />-l hav. and *illnrinrai. wo&cr{ conp€nxsrion insu!!trcc. as rcqltcd by Sccrion 1700ofrhc tihor Ctdc, ror rh. pcrfornuc. or
<br />lh. work lirr lhich rhis pcmil ii is\kd. My *orkcn comDcnetion insuratra cffiicr and polky numbcr m:
<br />PolicyNumbcr-L
<br />y'l.cniry rhd in rh. pcrromh... orrhc wo aor * hich rhh Frnir is issucd- I shatl n.r cmrtoy lny rcnon inrnym.nncr
<br />so !s lo bccrrR subjccl
<br />'o
<br />lhc wo.lcs' .o.!.nsarn,n hws of Cllionn, and asrc thut if l rho ld hccom subjccr lo rhc
<br />sorkqs q)flrFnsutionBrvki.nsolSNtion37mufrh.IjtnrCr..Islull,fo.rhsirhonplywirhrhorpovnion\
<br />WARNIN(;: F.ilurc ro \ccurc sorlcr @mpcn$rior corrirc ir unl0winl. rtrl rhrll suhjccr r. ctrlltloycr h diminal pcrkrra\ nnd
<br />.i\'l ln,o\ np ro onc hu r.J rhou\a JolL'\ lsl(xr.{xN))cos ofcoqrc.salio.. damrBcs.s tnvid.d ror ihc
<br />S..ri(n 1076.frhr Lrhtr(1n1.. iJ rr.n rnl rno"rv \?/tt//0 n,,,*,,r
<br />LICEII,IEILIONIBA T'f,
<br />DECLAAAfIO!
<br />I lErcby artrnr undd pcnally.flErjury rhd I an li.cnscd u.dcr nolnion olChaflcr 9 (oftmncins,nh S(lio. 7000) or Divnioo l
<br />oi lh. BusirE$ Md Pbre$io6\ C6d.. u.d my licc.\c n in flll foe und eilcct.
<br />c/o /oo(a[1_a)
<br />/, r/f "-*..x:E
<br />CONiIXI&IA IENDIN!i.A{,iENII
<br />I hcEby rmn.ln{lcr pcnahy ol,rrjur! th,t lhcrc is a conitu.ri)n bndins aacncy ror rh. r.rformsncc ofrhc wor* foi *hich rhn Fmn n
<br />ksucd (Sc. 1097, Civ. C )
<br />AIIIICANII'ECLTBATO]!
<br />I tmby rftim undcr pcnnhy orFrjuryonc ot'hc fdlowins drclaBtbns:
<br />D.mliriro P€rmirs Ashe(os Norificarion ltdersl RcBulations (Tirlc 40, Pd6)
<br />Rcqutcd Lxfl cr.f Norilicltn8
<br />I ccn iry rhar rh. lcdcral rcsulol ions EB.rdina ashc{os rc,tuvrl d. nur applic$lc rd rhh pbjrcr
<br />l.cdiryrh l hrlc rcrd rhr\ rnfliclriotr lnd srardh rhcnhovc inlo flri n comcl I r8re ro conlp], wirh all Cir y rnd Coud,
<br />ordiMn.cs rtul Srarc l,aws rclarilg ro b!
<br />6ovc nEntioncd pmt ny tu insrcction
<br />ADDll.anlor \!enl sirnolum Y
<br />.onslruction. ud hceby Nlhornx Eprcscnl ivcs of lhis Cilt ,nd Counly ro cnrd utbn rh.
<br />Penni,annnr (r,.inr): * iSrZl n a-;e- k-^,",, //tlB
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountalns
<br />Signs (monument)
<br />Life Satety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondi ng/Grounding/UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Ceilings (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />Rough
<br />Service lvleter I
<br />FINAL 7/t/rf .'r.Nt)D
<br />Notes Bemarks, Etc.
<br />ID/SIG,
<br />Walls (Rouqh)
<br />Meter Belease
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