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ELECTRICAL-INSPECTOR RECORD <br />COMMENTSDATEID/SIG.APPROVALS <br />Unde round <br />Pole Bases <br />Li ht Standards <br />S FountainsasPool <br />S NS monument <br />Life Saf /Low Volla <br />Fire Alarm i Dam ers <br />Communications Cable <br />Buildin <br />Under Slab / Floor <br />/ Groundin / UFERBondin <br />Translormers <br />uelnTo <br />Sub-Panels <br />Air Conditioners <br />menlRool To ulE <br />Facto Wired Unit <br />Walls Conduit <br />hWallsRo <br />Ceilin Hard & Soffit Rou h <br />Ceilin hST-Bar Rou <br />Meter Release <br />t2Rouh <br />Service lvleter <br />FINAL <br />Notes, Remarks Etc <br />lhcrcby!fllrfrundctpcn.lry(r,'.rjurylholld.xcmprnomlhcConlmcroFl-ic'nsLrwibrlh'folLwin!rcasnlsc(70115 <br />Busincs Md Pofcsion Codc): ADy Cily o. Counry whEh dquircs a Pqmir lo otrsrtuct. tlrcr' iq'rolc ddrmlnh or frl[lr rny <br />slruciuE'pliolbirsn$,ncc.okorequircslhcopPlicanlf.rsu.hFrmillofikasisnedslol.mnllhhtorshcisli.c.scd,)u6ulol <br />blhaPmrkio.solthcconra.i(rtLiccnscdllwlchqrlerg'commcnci.r*ilhscclion?o0oolDivi\hn]]oflhcBusi.c$0trd <br />p,Dics;io.q codc) o! rhat tEo. shc nc&n!fl rhcrcfrom and rhcb{sis lorrhc,lc8cdcxcmptn,n. An, viotarionofscctiodT0lr.5 hy !try <br />arrpli.,nr rorapcmn suhjds lfic upllicrnr ro 0civilp€nahyofrcl nnr. rh fivc hlndrd dollars ($500)' <br />l. as ownrofrhctmFny. or my cnllorte\ wnhwaScs!s lhcn \.k onrrEnsnrion. will do rh. wolk !'d rlE d tuN i\ fr <br />i,'r""Lt - .neea r"i *i tie.7oi4. Blsituss aid Prcltsions c{,lc Ttc co'rEdors Liccn* l-ss docs <br />'oi 'prlv ro !n owncr or <br />lfic pmrcny wh. builds or inpmvcs rhepn turl sho dms sEh m& himself or hcscli or rhDUBh hh ot hct orn cmnk']vccs' <br />-"*a"a tr,* *.r. 'nmtmlL d mr orcndcd or ofic(n for ek lt hoec$r (ht hnildirA '! itr{xdcmN is vnd {irhir onc ,i{ <br />;rcoryhrntr ltr O*mr Burbs *'llhtrw rhc hrden olPmvin8 lhar hc or shc dU mr build or inlPnrt rh' pmlEry for rtE purF*of <br />l. as owner dr rhc nBpcrlt- ,m .rclusilely coordins eilh liccn*d conlracro^ ro 'on(ru'r <br />rh' rmjed rs*' 7(}'4 Ausi"c$ <br />u,a p*ro..hCoa",ir,"cnnrtElo,'sLiccnsctjsdocsnoralllvroanown.rofpn'pc,whoI'uil'lsornnProrc\rlErcon' <br />ind $ho onrBch for such Pbjcc wirh s C.nrmclonI licen{d luNunr ro thc codracft, s Li'cn$ l'w)' <br />()$\Itk BL ,tn,.l{ l)l ] ( \ll,\'l ll)\ <br />_l anrcxcmfl !nd.r sc.r <br />Policy Numtc. <br />- <br />Liccnse Chs: '---Li..nsc Nuhb'r <br />- <br />r\sucd (Scc :1097, civ. C.l <br />Erlires: <br />- <br />Ij}BtrEIILIjIJMPJNTAITON <br />DECI.ASAtrON <br />I h€tby afnrn lndcr F.aIy of p.d!ry on. of lhc followinS adrrtrrion\: <br />Ihlvea'dwillminloin0c.niflcllcafc6n$nrlos.lf-lnsurclorsorkgionlp.nsolion,aiFovidcdforhysdion]7mo(ll8 <br />rib.r de- for rhc pclolmne or rhc woi( for which rhc ,).nnit is isru.d. <br />-l <br />hNc snd pill mri.rlin *orkcts conp.ralion insuEftc. s\ rcquiEd bv Sccl iotr STm o, rh' tibo' Cod' for lnc !'r"rmlE or <br />rl* sork ror whth thn p.mir is hsu€d My *orlcR conF.sdrion insuGEc fftr and Plkv nuhhcr el <br />-l <br />ccdityrhur inlhe p.rlornBnceofrhc work iot *hichrh^ F,r i\ h\xcd l\hnllnL cmflovanv p'rhn 'n'ny mrnn'r <br />-tr,ht-"*{hjc.il"rh.*"*cr'olnFru'onlotr.nr(nl'ntrn.onJ+nrrh. IlI 'h'uld h'c'm {hJc ('rhc <br />workcrs' cotrltnsaiion pmlhions of Sccl ion .r7m ol rtu L,h, Codc. I \hnll rodhwirh oq'lv wilh rho$ Povisbn\ <br />WARNTNC: Friturc ro ssc wo*cB compctrsr.on ovcm8e i\ u.h$iul. aid shall \ubjccl 'n cn!not!! tr rin nrl Fnrlrts 0nd <br />civil fitrcs uI ro onc hurdrcd rhousand dollrrs (sl00.O0O). in rddtion nr rhc.on ofcor$nsarion ddnhS's 0s Frvil'd lor rh' <br />sccrioo 3076 of th. tjbor C{xL. intcrcsl snd ,tormv s fes <br />D e- Appll@(:uc.rsrn ct-mrmrrtrn <br />- <br />DEIIdf,AII!]! <br />Ihcrcbylmrnund€rpcnalryofp.rjuryrhdlddliNnsnwlgrtvisionofChaplcr9(c'mm'cinswilhSdbn?000)orDivision <br />ot rh. Busines and Prcfcsiots Codc. !d my licenrc is in full fod dd cffc.r <br />IONII3UCNANIINDINj.ECEN.CI <br />I hcreby dfti,n undcr pcnatry.lpcdnry rhd rh.o is;onntudion lcndira {cncy fn rhc pcrfonrHNc ofrhc sorl tor vhi.h lhi\ pcrn r is <br />APPI !(IANT DECLARAT!(TN <br />I lrEhy a,fim undcr pctralr, orlcrjury one oilhc lollosins dc.ladions: <br />Denolirion Pcflnirs A\bc{os Norifi.dlion r{dc!01 Regulnlions I rnk 40. Pln6) <br />Rcquncd lxtrd or Notificlrio. <br />-tonirylh <br />lhe lcd.raltesularioi\ 6g0rdins osl,.sros rcmval.rc n.r 0tPlic lcturlirrmjccr <br />-IccnilylharlhrvcrcadrhisQplicalionandsr,retharlhc0tnvcinrdnElioris'orcl'l4,eki'onflysnhsllCitvandCounivoai""il",i"a srae r"*, *r"riii io huildins .ondrudiotr ed hcrcby.urhorire rep,.senhrivcs ofuhk ciryaod counr, ro cnr$ upon rhc <br />abvc mnriored DDp.ny ror i,spcdion purposs. <br />Applicanl trr AEetrl Sianctur. <br />Site-Work <br />( <br />Gndcls Add6ss: