|
ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DI]LCARATION
<br />I hcrchy aliinn undcr t nnlry oi pcrjury thel I m cxcmrr rnnn rh. Conka.rotr Li.cns. hw lor rhc follosinS rcasn (5(?011.5
<br />Bu\incs and Pnr.ssion Codc): Atry City or Counly which r.qutcs ! rmir lo con\lruct. all.r. imrmvc. {hmrirh 6r rcpun aiy
<br />strucrurc. prior ro irs irsuancc, dth.cquircs rh. dmli.rnr fif suchpcmirro lilc a iigftd 3rorcmcnr rh.r h..r shc is licmsed purueni
<br />ro rhc pmvnnrns oflh. Contracro.'s Liccnscn h* (Ch.prcr 9. Commncins *irh Strlion 7Om of Divhioo l.r $. 3urin.$,dd
<br />Potcsn,n. Code) or rhal lr or sh.
<br />^.rer{,r
<br />rkEfroft nnd rhc hrsh tu rhc dlksci .rcqJrion. An, vi.lilionorSdionT03l.5 61 0ny
<br />lpllicant lor a p.mit subjels rhc lpplicanl roacrvilpcnahyornor nrrcrhan nvc hundrcddollus (]!5(x)).
<br />lflp-. .**, "r,,'" n.p"nr. or trry cnlnli,rc\ wirh ss8es rs rhcn sok conrpcnsrrion. willd{, rhc sel lnd rhc {lmrc n nor
<br />,ircnd.J nr ,,rrcrcd n tr sh I S( 1044 Bdnnc* ,nd Pnntssnnr C{'dc Tn. Conka.ror r Li..he lr* {iocs .or amlt to 0n o$rcr of
<br />rhc lmlrc y who huilds or imorcrcs lhcrc.. irrd who docs nrh wo& hnnsclf or hcnell or lhmu8h his or hcr own empioycF.
<br />p.olidtd rhur such irlhm.rs m rtn inr.ndcd oro,Ic(n for qlc ll howi rhc hiHin8 or impmvcmd k $ki wirhin onc Fd
<br />ofcomplciion. rhc Ownur Buit & sill havr ttr horddi oftmving rhd ne or.h. did rx hoild or i'qrovc rh. pmFn, for lh. purrxie or
<br />I hcrcb, llftr undcr l.n.lryofperjuryone otrhc r'ollos ing
<br />IhavcaJ eill roinrrin a Cen ifrar. of Conscnr ro Sclt lnsurc ior *.rke.s rcnt nsarbn, ln'!id.d ror by Sc.rion l?m ol lirc
<br />tibor Codc. lor rh. Frfonm'Ec of rhc wolk ior which rhc Fnnil n issucd
<br />lhalc and *illmainriin oorler'.o'.pcns{i.n insurancc. !s rcquircd bySccrion:1700ofrhc lilntr Codc. fo. rhc frlonnrncc ol
<br />rhc sl li)r*hichrhis pc ir is isuLi My workcs'.onrp.nsnlion tNro&.crricrdd policynun$cr ecl
<br />PolicyNun$.r: Exltr.\
<br />ffif,."n'ry rr,a . rr'" p",i,,,,nrmc or rhc tro,t,n' trhrh rhis rc.inir is iss!c<r- I shrlr tr,r cmploy Dny peB,n
<br />'n
<br />nny mannf
<br />'q,srr,hdc,,nr\xhFcrn'rhre.rkcilonlIn\Jrionl,k.fCrlifinnis,tridrgrdrldiflshouldb.corEsuhj.cllorhe
<br />*ork.m omp.ns,ion pmvhionsofSelion l7O0ofrhc Uhor Crrdc.I shrll. rodhwilh smply wilh rhoc,mvkions..
<br />W RNING hil'trc n, {.nr. {dhc^ con'prnsrri,nr.or.rxlc i\ unfur rrl. sid rhall ruhjccr an .nploycr to riminol n nrhics md
<br />ro rhc cod .f.ofrp.nMrion. drmB.s !s rrovidcd for rhccivil fifc\ u! r. om l,tr rrd rhou\rn,l dollr\ (Sl(x,,(XX)). in 3{ldil
<br />::: +{rb]14,Appliont:
<br />lhctu5y trlllr iuilcr nrdrlrr-r, f'crluryrhd I nD li.cnetuidcr hion.rchaprcr 9 (.onnmming wilh Sarion ?(xJO) oaDirision 3
<br />of rhc axsi'rs rnd P tsionsCod.. md 'nylicctr\c is in full fn.. fll.ftccr
<br />(oluBlJcllaNrllDlxr.i-&G[Ncr
<br />I h.thyttitntn rr p.ndlryorl,.rjur!rh nNc i\ r.oinrdi(nr bndiie aA.my lnr rhc |xrtofMr.c oithcwork r'.rshichrhis pcnni i\
<br />t\ucd (sN .t097. civ c )
<br />Lcndcis Addr€ss:
<br />-ffi,ffi;
<br />,idcrrlrcguLri,nn rgn i',E r\b.{o\ rcnntrrlrr. mrrmlic hlc h rhis piojccr
<br />rcLd rhisdmli.rri.nrfrl{arcrhar rhcsh)rc inf(trmdit i\.olNr lograro.omplyEilhallCily3ndCounry
<br />n \ '.lI nE r,' htr'Lli'rg (rr .rn,n. MJ hcr.hyrtrrhoriz. rcj,rc\cnlrrilc{ ofrh^ Ciry rnd C.u rryr
<br />ilDr mnrioncd l,lol'cny {or insp.rlion
<br />aitrAppli.anl or llR.trl Si8non'rc
<br />1+
<br />L-^/(utt&la
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Bouoh
<br />Ceilings (T-Bar Rouoh)
<br />lt/leter Release
<br />Rough
<br />Service Meter
<br />FINAL bfL+,/lcA sb<l
<br />INotes, Remarks, Etc.
<br />-1.
<br />N own( of rhc fmpcny. rnrcxcluvvclrcontrnrrirr *nh lic.trscd.o.lrrcloslo conslrud rl'€ rmjecl(Scc 7l)4t, Btr\itrc.\
<br />anl t\Dllssbn Codc: TficContacroi s t-iccnsE l-awdocs nolrpplyro anornd ofrrcp.nysho build( orimtrovcs rhcrcon.
<br />and who conlrrkl.r such pn,jEtswirha C:onrrocrtrG) hccn*d pusur.r lo rhc Coi ndois Licensc Law)K\0
<br />Li.cnsc Chss: Ltun{ Nunrbcr
<br />Dors: ( onlro(lor
<br />AIILTANfDIiCIA8AIION
<br />I ho!{ry !ftm undcr pen!lry ol p€rjury onc ollnc followinB d(brcrions:
<br />Dcmolilion P$nirl^sbcsos Norilicatio. F.dcml R.euld io.c (Tillc ,10. Prn6)
<br />-R€quind
<br />t ner orNoiic{liotr
|