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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE tDistG.COMMENTS OWNER BUILDER DELCANATION
<br />I hcrcby oftirm undcr pcnalry ol pcrjMy lhal I m €rcmpt amm lhc Conrmcro6 Lienc Lr{ for rh. r.UowinE rcann lscc.7ol l .5
<br />Busincss and Profesion Colic): Any Cny or Counry which rcqun.s N rsnir ro $sldd. altcr, improve dcmlhh or rcI{n loy
<br />{dcruc. pri, r. irs hsumc. als r.qutcs rhc !p/i.nt lor such l€mir ro filc a sismd shrcftnr rh, h or ihc Li liccnscd puNr.t
<br />io lhc pmvirions oarhc cont.cror's Lion*d kw (chaptcr 9. Comrcin8 wilh Sccrio. TO0O of Divirion:l or rhc Busincss tM
<br />Prolt$ions Codc) or rtat lrc or shc is €xenpt rhcrcaron 0d rnc hash nr rhe allcged.r.nDrion. ary vblalion ofSslion 7031.5 hy aay
<br />lffllpnr t'r arcmirlutslNr rhc d|IIltrrnrx, 'c'vilp.nrlryoln.r'mr rh,n rtr. hundrcddnllesrtrsur,I /t
<br />/LZr. l. d**, .r ,* p-r"'U. .r my cmnl.rr\ w h w0acs $ rhcir sole con,pcnsorio!. *ill d{, rhr wolk a.d rh. slmrE ir nor
<br />' inEnd&/or oFscd for qk ( S( 7tI44. Bu\irrcs and Prnfcssionc Codc Thc Conkdur'\ Liccnsc Liw dmi nor lnrly lo !n o*rcr of
<br />rhc ImD.dy wlt, h{ilds or inmrcs lhcNo. ald who des ssh *o* hinselfor h.rcltor rhrcuBh hh or hcrown cnl,)hyccs.
<br />providcd rh su.h inpmrc.Enh m nor inlcndad n orM lnr sh. lf. horcEr. lhE building or i,tDn,Eftnr ia e,U ahhnr o.c )tr
<br />ofconphrhi.lnc Owrcr Blildcr will hat rne h!dc. of pmrins $al h. o, ne dn n hrin ot inpd,w fic,mFny for ltr NqFs of
<br />-1.
<br />!s owncr ofrhe pm!.ny. !m cicl!{ivclycontmriis wirh li.e.\cd.onlra.k,r ro..nslru.l rhc pm]ccrlscc. 7044. Bu\ir'ct\
<br />ard t\bfs\irn Codc: Thc Conr..rDr's Liccnsc Ij* do.s nor rpply ro an owmr ol poti.rt, who builds or i.,pruv.r rhdrcnn.
<br />ond *ho .oracts tu such prerccts wi't a Contrrr'rG) licenscd runuunr lo rhc Co Ecn \Li.cnrlrs)
<br />;:]u|jC
<br />I hcrchy.inm utucr pcMlryotpcrjuryorc oalhc lollowin8
<br />Ihav.undwillm"iduinnCcdillc.icolConsc.tloSclf.lNUrcforworkcs'(nnpcnnion-Npn,vi,lcJlb.bySdclnrn:l7U)ofthc
<br />Ljt-r Codc, for rhc pe.{.rmnc. orrhc hrk for ehi.h rhc pdnir is i\u.d
<br />I hnvc (trdsill nrairrain workerr' compcnsrlion insu,rncc. !s rcqtrncJ hysccrk,n 17t[olrhc hhxCodc, tor rhc pcrforronce ol'
<br />rhc work lorwhicnrhhn rmir is issicd Mywolkdi cooFnurn,n insnhftd.ricr rn NIicy nunrbc, rc:
<br />ENc ofrhc wort lor *hi.h rhi\ Frnri n issucd. I sh0ll nor cmploya.y pc^on in nny nrnn$
<br />workds compcnsdi(in lnwsol Crlilornir. andu8Ndhar ifl \hotld h.{o.rc \ubl..r I'lhc
<br />WARNINC: liilurc ro ccurc $orlcr compcnsarion courrsc is nihstul. aid \hall rubjc.r arr cn9hycr to riminal pctrilii.\ r'xl
<br />civil 6nc\ up ro onc hun
<br />Scrrion 1076 otrhclinr
<br />DIIC IVU ti'lx
<br />lLrr\ i\llxr lxxr) in rddir t, rh...n orconlpcnsrrnnr. d8nRgcs tr\ p(,vidcrl fitr rlt
<br />I hcrcby.llirDuMcr jrn.llrof Dc.jurylh l a rlienscd undcr iiotr orChrprr 9 (efr!ftfl.in8 q
<br />of rhc ausi..ssand Pmfc*ions Cod.,0rn nrr lacos is in tullforeodcfl(l
<br />coilslrucuoNtElluNclcENtr
<br />I hcrcby aflim lnds Fnalr, .l perjury rhar rh.rc ir . onsrrucrhn h.ding aScRy lor lh. pcriomurcc of lhc sork ror shich thn trmit ir
<br />ksucd (Scc 1097, Civ. C.).
<br />AfIUCANfDECIAEAIIO!
<br />I hdtyanimundcr pen0hy of perjury onc ofthc aouosing d€claraliors:
<br />Detulhnr Pdnnl Asb.sos Norific.lhn F.d.ml Rc8llnlions (Tirlc40. Plln6)
<br />-Rcquircd
<br />t llcrof Nolnstion
<br />I-l Lcniry rhI rhdnluJl rceulJr'.tr\ rs,rJin8 0
<br />4[*,*:*lr,rrl',ri;r*r[iltJ:r;
<br />ahrvc ftmnnrd pft,pcdy lnr inspccrion pury,*s
<br />i\ cotucr I ngrcc to.onlnlv {ir
<br />(/
<br />,\prlirinl o' ,\sr r Sixnnl,'m
<br />1Tt W la;g'"
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueing
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Solfit Rouqh
<br />Ceilings (T-Bar Rough)
<br />Meter Release
<br />Rough
<br />z(l
<br />FINAL % b\L1\\'7 ,lllt (i1
<br />Notes, Remarks, Etc
<br />Sub-Panels
<br />Service Meter
<br />*ollcr' .omFn\arhtr flolisions ol Scd ion ]7fi) of r h. tjttn L'odc. I shlll. fonhwirh comlly $irh r,x,€ tn,visions.
<br />Liccnscch\s: Liccnxc Numhcr
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<br />t)'lE: Conlr.rto.
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