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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE tD/stG.OWNER BUILDER DELCARATION
<br />I hcleb, amrn u.ler Il.mh, ()l pcrjury rh l !h cicmpr from rhc ConrndoN l,iccnse tjw fi,r rhc follo*in8 rcavr. (Sc.70:ll5,
<br />Busircss and Pblcssion Codc): Any Ciry or Couniy whi.h ,cqui(r r J)cmn b .on{fl.r, drcr. improv.. dcrmlish or r.lair dny
<br />{tucrurc- prior b ns issuarce. alh requncs rhe applicanl rar such p.rn ! ro lilc ! \isrcd (llemnl lhar lE or shc k liccn*d pu^uanr '
<br />ro rhc pmvisions ofrtr Conl!0.lols Liccnsd Lnw (Charrn 9. cormcncin8 wirh Sc.lion ?fi, oI Oivtion.l oflte Alsincss trnd
<br />Pbrcsn,or Codc) or rhar hc o. shc h cicmpr rhercarom ond rhc l,rsis ror rhc lihsed cic,nprion An, viohtionorsc.rhn 7011.5 by,iy
<br />/iittl(Jd lor.t rn uhJc.rh. rnnlranrL,J.^'lF.r\rnrni m,rrhJn I'v. hunJrddullJ\ r(<uo,
<br />({F,:,r"1:ltt,fli^:i&T:}:.:;t;},1;::.r:,1[l,ll;lHt;t"i.il:fl:[tT*"ffil:::T1",",
<br />lhc pmFn, who builds or irymrcs rhcmr md vho des such *.rk hinNclfor hcnclfor rhrcush his or hcr owncmnlore..
<br />pi(,vid.d thar su.h impokftnh m @r imenla:d or olr.Ed tor elc ll h.*cEr rnc toilding or irrgmkru is skl *irhin on. Fd
<br />ol coinrlcrk n, rh.Ow.cr BuiUd will hxw rh. bnrdcn ol'poving rhlr l- or \hc dil trn hoik or i'pmvc rhc pn,pdy f{, drc puqbr ol'
<br />_1. $owftr.lrh. fo|frrt. amcrchrivcly..nL,.ring *irh li..n\.d c.Drkro6 b con(rud rh. pmFcl (Sa. 7041. Bunncs
<br />d tmlcxsi,n Orde: The Conlracrols Licensc l,ow docs not apnly ro (. ownc, oap.oPcny wno builds o, impn,te\ rh.r.on.
<br />and who conhcts for ruh pnrc.ls wirh r Co a.k(s) li.c.s.d putrxdr o lh. Cofir.ktr s Li.ctr* Law)
<br />-lnrcrcrn
<br />uldcrS+ron - .8 aPr'u.. lilal// u.*".wl'/ l'6
<br />I hcEhy afirm undcr pcn.lty ol pcriury one oalhc folLwinp d(hmrions
<br />I hrlc irnl will.rinriir r(tnll.d.ofCo..c r, Srlal \urc ftn q orkcr l' L.nllttr\{nnr. !s trolldcd
<br />Lrtxt Codr. n, rhc pcrfonuicc olrhc lrork for trhi.hrh. Fnnn n istr.d
<br />_lhrvcnndBillm!inrliruorkcn compcnsllion insur.ncc. rs rcquircd by Scclion:l7lro oirhc uhor G'iL. tn rh. p.rronu.cc or
<br />rnc work tu whi.h rhisFrmil is i\s!cd. My$orkcs conrpcnsrion inrurmcc c! cr arrr Fnicy numhc.u:
<br />cnploy dn, I.6on in any mmmt
<br />and rlrcc rhd rrl should heonE $$jcr ro!h.
<br />shnll. $nhsirhcom0ly wili rhos nrovisionr
<br />WARNINC: FniluE lo scnrc $ork.r' .o'nFnsllion colcn8c ir utrhstl lnJ (nU ixbFr an . lploi$ r, ninn. l lxmlriN lnd
<br />civil fincs up lo onc hundrcd rh.usnd do
<br />::,""^u{oJif"l
<br />nsrri,n,. dtrtr gd( r\ pnrid.d tur thc
<br />I h.rby.lrirtrrnndf p.nalty of pcrjury thol I ar liccn\ol bnolCh rLr 9lcomrmncins Nirh Scclian TOOO) orDilkn'n.l
<br />of rhe Bd\incs\an Profe\\t,nr 0'dc. dd rtli..tr* n ir lullinccdirficcr
<br />CANIIAIJCIIANJ.IAI}ACIqENCI
<br />I hcobyarionundfr.mltyorpcrjuryth.t rhcrc isrcotrsru.ri,n l.idinga8crcyf.r rhcpc.lornumc ofthcwork ror which lhis pcrm n
<br />is\ucd (Scc :lo9?. Civ, C )
<br />Lrnder'i Addresr
<br />-
<br />APIIICAI{fIEIIIBAIION
<br />I ltJtly o,tim undcr rcnrlry orrcrlury onc.r'hc tullowin! dcclaraln,n\:
<br />Dcmolitin PcnnirrAshcao\ Norili.ation rtdqal RcBUl.tionr (l illc 40, P0n6)
<br />-Rcqrtcd
<br />Lcrrcr oI Noriliorion
<br />M,o*
<br />ilirlBr rlt lc,lcfl'] rcgt!rri,n,\ rugxrJn,g r\lx(o\r.nrnrlrr trorr|nli( hlc n) rhi\ |rrc.r
<br />rhd I h,!c rcnd rh^ lPrlicrrn,i rnd nrrcrhd rl( fi,ec inlnrnnriDn '\cond I rgR\ ro.onlllly wil[.llCiryatrd Counly
<br />Srrr.l,rLv\ (hring t, l i i'rg.
<br />rbove mnri,rncd pmncny lor insDccrionruryn
<br />ApDlicanl or Agenl SiEnntur.
<br />r\b
<br />;::,)i;/,6
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundino / UFER
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Rouqh
<br />Ceilinqs (T-Bar Rouoh)
<br />Meter Release
<br />Rou gh
<br />Service ltrleler r\
<br />L-22-t(ll,lwtil
<br />Notes, Remarks , Etc.IJ
<br />COMMENTS
<br />Transformers
<br />FINAL
<br />rhxr in rh. Fn.rnum of rhr eorl l(tr whi.l,
<br />suhjr.r brh. wo*ns compcns iotr hws
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