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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE IDiSIG.COMMENTS
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab i Floor
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Bouoh
<br />Ceilings (T-Bar Rough)
<br />lvleler Release
<br />Rough
<br />Service lvleter
<br />FINAL I / rr,/t{)
<br />Notes, Remarks, Etc
<br />- o.'(/
<br />OWNER BUILDER DELCARATION
<br />I tErch, amrn under pculr, of ncrjury rhar I !m cicmrrr fron rh. ConrracbN Li.rtrs. Ijw ro. lhc iollowi.S rcnbn ( Scc.roll.5
<br />Burinc$ dd Dor.$bn Codc) Any Ciry or Counry whi.h rcqxirs ! Fi,nir t, otrnrud. allci nnprolc- dcmlhh or rcn, r ony
<br />slru.rurc. ,rio. ro ik nsudtrc. ,lso mquncs d. lpplhd lor such IErn t) lilc a siSn€n slrlcmnl lial hc or shc h licens.d ,,l^u,ni
<br />h rhe povhn,is olrtr Conrtuttr\ l.iccnscd liw (Chrrrer 9, Conm.n.ing wnh sccLon 7un nf Division 3 ofrh. Busincs and
<br />PmrcsrionsCodc)orrh{rhorshchcxcnlrrhcdiomrndlhcbnsicrorlhcallcBcdcxcnrprion.Anylt,lario.ofSeclionToll5hyany
<br />appliclnl for a pcmir subjcclsrhc atpli.ml to Bcivilpcnaliyolnor m,clhrn lirc hutdrcd doll$ ( S5m)
<br />l. * .wnft or rhc polrdy. or mt .n lorca wirh wngcs as lhcn $k .omp.ns.trn. will do lhc wok and rhc {eh h or
<br />i cndcd oron'crcd for slc (Sa'7(}14. Blsim$ rnd ftofesions nrlc:'l'hc C\trk.tr's La.trE tjr docs norll1ply ro nnowmr oa
<br />rh.Impcny who buildsor inlomrsrheNn, eod wno docs such srl hi'nacll or hcMlf or rhmuBh hir or hq ow. cnrlLyccs.
<br />lri,vilcdrhar such idtoirftnh ft mr inlcdcd droficrd for$L.If. hoscri thc blildin8 or irymrcm n$ndwi.hnoi.,u
<br />oac.q,krion. tL Owmr Bui0d wiu harc lhc hudefl of,,ovinB thrt tr or \hc dil nor r,likl.r i.rpow th. tmFiy ror rlh purins of
<br />_,. !sownerolrh.lmDcny, amqclusivclrco racrinssirhliccnscdconr.lctrsfuL$n$ru.!ihcptuc.rlsc.7t|4-1.aunrcs
<br />nnd Pnrt*i,Cod. Th.Conta.ro.\l-i..ns.L,qdftsnorltnlyro,troR.cr.fl)lot.nywhohuildsorim[ovcslhcrcon,
<br />.nd who onlrmls lor nEh [ojccrs wnh ! Co ruchno licctrsd pusulnr ro rh€ Conlncroi s Liccn\e ll*)
<br />l,ncrcnnr uMcr Sftri(
<br />jll)BKEtsl':ljaMMSA.UAN
<br />DIICLIAAIION
<br />I h.r.hy rfii n undcr !.nnlry ol turury oN ol rh. Llb*ing dNlrdrirnN
<br />Ihtrlrud\illnrinr,inICcnilkrrcof(i rsc hS.l \ur.tuworkcrf.on{cnsrllotr.rslrolidcdI{nh,S(rbn]7fl}ofrhc
<br />litxn Cod.,lu rhc pcrfonnrm. ofrfic work for whirh rhc ltnnn is h{ucd.
<br />_lhrvcondwillnuinllin*orke6comI[.aioiiistnncc-a\rrquiEdhyS..rn:17(Dofrhclib.r('onc.ttrIhc,Erl'onMic.ol
<br />rhc work li)rNhi.h lhis pcn,ir is h\u!l M,worteB conD.isrri{nnNUr d.add rtrd tDlrytrtrtr$cr ru
<br />Ceicr:-
<br />I'.li.yNu rhcr-E(Iircs:
<br />-l
<br />ccnity rhrr in rhc pennrnumc ofrh. N.rk lr shi.h rhi! t rn,ir t n\u&I. I \hrll nor cn\roy rny r$s.tr ir n,ry rnrtrncr
<br />v' x\ t, scconr rubjer ro rhc workc^.otrrpci\rriinr hw\orcalihrnid dod 4N rlrrirl slx'uld tE(rN subicd r,'lhc
<br />$or*c^ comp.n\rrion pmvisi{,ns orSdn,n:170) otrhc l.rtxr Cod.,lshrll, n)dlBirh conply wilh rhosc pmvisioN
<br />WARNINCT Fnilurc ki $.urc *orken .ompcnsdion cov.r.Ac is unl0wlul. 0nd shtrll subrccr !n cmpl('ycr ro di'ninrl p.Mlris utrd
<br />.ivil fincs up ro.nc hnnd(.d thousrtrd dollrs ($lu),UJ0). in {ndnn.lo lhr.osr ofcomtc.\lrion. dtrtugcs as pbvid.d for rh.
<br />S.cr'nh.'u/6,,rrh. tlh{ C.dc. rnicrc{ .'ftI arbrrcy . lNs
<br />lpprionr: V
<br />Llt/E\sEn (oNTRA( T()R
<br />DECI,INAI:IO!
<br />Ihcrbyn,firmund.,Fnalr,olp.rjuryrharIrrlien{durdol]n)vi!i.nofcl[prcr9(conuEncin8wiliSarion7(x{r)orDilhio:1
<br />ol ltc Businc$ a.d Fmlcsions Code. ana my liccns n nr tull rorc. lnd .rdr
<br />x
<br />gairBuqrlrri.LElDAc-f,cEN(I
<br />I hcEl,y omrm under pcnlhy ot lerjury rhar rh€rc is ! onsrrucri.n hndins.see, tor th. p.rrormftc ofthc vork for rhich lhis pcrmil i
<br />issucd (S... 1097. Civ. C.)
<br />AIII.ICAITLDICIAEAUAN
<br />I hnt'y,trran uNl.r p.nilry of pcrjury one orrhc followire dcclrtr0rions
<br />Dcholiri{,nldrmirs Ast{sosNorificdirn Fcd.rdl Rcgulnri.ns(Tirlc40. PM6)
<br />-Rcquned
<br />Lcrrcr of N.rifi Llrid1
<br />-l
<br />aniiy lhal thc fcdcia I rcsu lal ions resndins 0$e$( rcmovulurc nor trPplicrhlc t, rhis pn,jc.r
<br />l.dilirh l hnvc rcrdrhh amli.diotrat s.rcth rh. nt rc iiformrion kcoiiccr I agre to comply sirh nll Ciry aid coumy
<br />orli aic.s n.d srrre llwr rclditrg ro buildin8 .onnfld t 6, md h.ruby aurhori- lcrrcsm ivcsolthirCiryandCouoryk,enrfiulonllf,
<br />i&)vc mnl ioncd tmpcny Lr iny,ccr ion puqrc*s
<br />,rpprienr or egent Stgnrhrr f,
<br />Pedile Nm! (prlnt):
<br />,,lril
<br />Itnd,-'.^Jd',!.
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