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ELECTHICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDER I)EI,CARATION
<br />I hcrchy smrm undcr penalry ot Frrury rhar I dn.icnrpr fmrn rhc Conrrr.bn Licctr* b* for thc follo*ine rcnstr lscc.?l).11.5
<br />Busirr{ and Pri,fc(\ion Cdc): Any Ciy or Counry shi.h rcquncs r f'cirnn lo cotr(ruc|. altcr. improvc. dcnnnth o. rpit any
<br />ffl.rurc, prnf xr ns is\utr..c. aho r.quios lhc {rrli.anr f.r such lfrmir ro filca si8trcd srarcnEnr rhar heor shc n li..nscd tud,nr
<br />lo rhc nmlisions ol lhc Conlradors l-i.cnsd ljw (Chapler 9- Commencin! wirh sccrn,n 7000 or Divnion 3 ofth. Busincs ind
<br />Pn,acssiotrs Codc) or rhar it or rhe t cr.rfl rheEfron and rhc hdlis ntr $. trllcgul.xcn9ri.n. Atry viohtiotr ot Sathn 70.1I 5 h, any
<br />Arrrrl.dg r' rrr' lubr{yrrrh. Jnrl'(,nrt,a.rvrln.n,lryulnnr'mrcrhannrchundmddnllaFrlS00'trtt,
<br />y [lLY. ^ "* rc, ,,r rhc poFn !. or mv c'nnloy.c\ * rh *Jq$ rs rh.ir n,k cnnpcnrario.. wirl do rhc "r* .d rh. srurE t nor''!.["a"a
<br />-"tr."t r.', *i" ria zoil. girrrc* ara pmrisiorr codc l]tc conrrocrn s Liccnr lir rL,cs mr artly ro rh ownr, .r
<br />the rrmpcny who l,uilds.r iryrcv$ lhc@n- od *ho des such work hims.lfor he^clror rhbugh hh or h.r own(mployccs.
<br />pmvid.d rhar su.h impn,vctunrs m nor i e lcd or ollcr.i aff srlc ll how.!s, rh. huibing or impmvcmnl is sold wilhi. onc )ear
<br />ofcomplcrbtr rhc Ouer Buikicr will hr\r {h. brrtlcn ofpmving rh,r tr or shc dil n t{il] or nlpn,vc ilt pmpdy lor rlE,Drrnsof
<br />l, rsowNr ofrhc pmFny. nncxcl$irclycontr.crire wirh licc"rd.onhcro6 n, con(rucr rlr lmje.r (s(. 7{E4, Bunncss
<br />and Pnrtcssh Codc: Thc Conrlcroar Liccisc Lr* diEr nor nprly k, snowncr.rpn,Nn, who builds or impmvcs rh.rcon.
<br />rnd who .o n B lor such pmjccs qilh { Contr tr(r ) liccnscd Dumlatrl lothcC.nlra({tr s Licenrc hw)
<br />;:l{){1
<br />I hcrchy ain'n uMcr pcMxyoi|{rjuyorc ollhc followirC dslmr
<br />_l hale u{i Nill mrinrdii a Ccnilcar. .f Con{.t t, Sclt:ln\uE lnr uorkcfi .onDctr$lion..s pmvidcd ior bySNliotr:17(XJ olrnc
<br />ljtxr. Code. for lhc per,or@ncc ofrh. work for which rhc Froii is t\ucd
<br />Inavcondsillnrintainuorkcr\'conrFnsartnrinslrancc.a!rcquircdbySccrn:1700of(hcDh.rcodc.forrhcnc.ioanrnccof
<br />lhc eork for Rhich rhh Firnir is h{ed My workcn .onrEnsrrion insulmce cari( ail F,li.y nrnb.r c:
<br />lov ntry pcnon rn !nr- m(nncr
<br />$or kcr( coNtxtrsrl mn |)lovnioN ol Sdiotr 37(x) ol rhc I jhn Codc. I sh!]1. fonh*irh con,pl, $ irh rhos ,(,vnion\
<br />civil n os trp h oic hrndr.d rhousrnd dolld^ (SI(X),o(X)). $ ld ,tr r) lhr ..\ ot.onfctr\xrotr.aop.p n'n"ia"a to' tr'"
<br />[rai{drrt-L
<br />I h.Fl,y rllnD untl.r n.nrlryol |r.rlry rl,rr I rf,|,..tr(lrn,l!,vi1i,)n orChtrprs 9 (..nnrrmirB wil
<br />ot rhc ausifts and Polcsiotrs Codc. ud my li.cnsc is in tull fo^c !trd cra€r
<br />COISIBIICIIONIENIINC.ACENCI
<br />I hercby amrm lndcr pcnalry ol |lcrjury rhar rhsc h E conirtuclion lcnding .8.fty lor lnc p.rfonMmc of lhc vork for shich rhir Fmii ii
<br />issucd (Scc.109?, Civ. C.).
<br />AITUCANI.DICI.ABA.IION
<br />I hcrcty afiim uder penalryolperlury onc orrhc rolk,winE dc.ldari.is:
<br />D.n$hion Pfinft sAsb.(os Notificnrion ftdcml ReEUldions lTitlc 40. 1'an6)
<br />-Rcquncd
<br />Lcttcr ol Norifrarion
<br />n lrrdil) rhr rhrtu,[r'1rtlu| ,,
<br />/,[r[r,,,,,,,,*," *,u,,^ ",n,,,AJir'.'tr(c\.rnd \r. c l.itrs rclirru ro hui
<br />rtx,vc nf,Drnn(d pmp.n, r(tr irtncrn)n
<br />ADlrlicanl or l8cnl SiBnnlurc:
<br />(s8ed'nCsih.i.r'cmlolrrc n"r lnnlKal.klnthNlroi(.
<br />ion and slarc that Ih. obvc in,n'Eii,n hco tr. I lgrd '. .on ly vnh .11 Cily ond Counly
<br />rudhn- d furchlrtrrhori^ rcprr
<br />wl
<br />"-"'""'r'l'iffi- ","
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safely /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rough)
<br />Ir,4eter Release
<br />Rough
<br />Service IVeter lr-;\
<br />FINAL 0/tt/t{NMhA 4)
<br />Notes Remarks Etc.
<br />in lhc pcrr'ormncc o{rh. so r{r *hich rhn Frnir h
<br />subjcr ro lhc w.rkc6 .onr.ns.iion hwsorcdifornh.
<br />WARNIN(;: Irllur. r, \c.urc qorkcrs o rpcns ridr.o\c'r!c 11 tr hsinl. rtrd nmll suhjccr r0 ctrlPl{iy.r l(, qi4id.l Firhi.s d
<br />Lc crs Adtlrc$
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