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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS ID/SIG.COMMENTS OWNER BUII,DER I)EI,CARATION II h.rcby artr( undo pcnalrt or r.rjury rhar I m.r. tlr {mnr rhc Conrr.roF Lie.sc tiB lor rh. iolloEinB rca..,n ,Se 10.11 5 '
<br />Busincss .nd Pdt$ion Code): Any Ciry or Counry shih rcquircr ! Irnnl ro onsrtucr. dlrel intovc. dcmli\h or rcl)at atry
<br />ddcrlrc. pri{, ro irs hsuGc. also rcquircs rh. lpplicanr titr srch Fnnir ro fi|. a !i8n.d nd.md rhar fu or shc is liccnsd pon\anr
<br />ro rhe F)vi.nrns of rhc Co r!.rols Liccnsd tiw (Chaptct 9. ConmctrcirS wirh Sccrion ?fix) of Division I ol rh. Bnsinc$ n"d
<br />Professnn*Codc)orrtarlrorsneiscxcnrflricrcfronaidrtcba\nfffrhc,llrscdcx.rtrio..AnyviolirionolSalion70:11.5hyany
<br />lnplicair iu r t rdi' slhj*h rlE 4rlica ro u civil p.nrlry . r nd frndhan fii. hundr.d dollan ( lsuj).
<br />lvaa$r&i:lau$lrallaN
<br />DKLAtsAIION
<br />I hcr.6y rilirnr u c. p.nrlryofp.rjur!aN olrhc tulL,,u i,r! ,lc.hBr i,)ns
<br />-l
<br />n.vc lrn*ill Nintli. aC.nificlreolConscnr x,Sclf lnsure ln, {orkc( .onpcnerion. ,s pFvidcd lbl hySecrioolTtI}orrhc
<br />L.h, cdlc. r'.rthclxrfonn,nccollhc qolk torwhichrhc pcrmil n hsucd
<br />lhavc lnd sillrnrn r n rorkr$ .oD,trn\niion in{mncc. r\ r.qun brSccrion:17(X)olrh. Lnb.r G c.larrh. Nrfo'ntn.uol
<br />t0 /-iLDn'U-** "Eicr d F icY numbcr m:
<br />Y4oa'/'/ ?it t1,',2-
<br />I.cdiryrhnr in r hc Frfortuncc of IIr s.rk,r whi.h ihi\ piinn h nsucd.l shrll norcmpk,y atry pcrs,n in riy mrnkr
<br />s, slolE.omc sbjcd k) rlEwo*c onrpcns iotr liwsofcarilnnii. und lsrcc lh,r ilI sh,xld bc.om sbjcd Iolhc
<br />*ork${ conDens,rio. nrorisionsofSslion 3?00 of lhc titrr Cdc.l nrll. f.nh$irh Brmply qirh rho$ [.visi(,ns.
<br />WARNING Fdlurc ro Lrnrc workcB com!.nsdiotr covcm8c n unhwtul. lnd shull slhjcd Bn onploycr b dininal JEuhas 0d
<br />.ivil fincs ut to orc hlndrcd thousand dollrrs (S100.0m),
<br />'n dd[i.-n ro rhc con nr compcn\srn'n. d0mE.i r( r,rovilcd thr lhc
<br />sccrnn.rulooirh. t{b.raoJc. inrcrcn a arrorm},lR' - t
<br />".,".
<br />,q 7 8 -'q noo,,*,, *1\$Qg,
<br />Lr( ENsHoty'rRACToR
<br />DICIdAAIIIJN
<br />I hcrby litfln und.r p.nulry of p.rjury thst I am lien*1und.r pmvisio. olChaplq 9(commminE wirh S*riJ.7uJ0r orDivhi.n l
<br />oi rtc Blsincs md Profe$ionsCodc. ud 'nylic€n* h in lull lorce urxl tfr.cr.
<br />/) B Ct/)5q7
<br />16',,.,'
<br />oi -Z I 't c-n""r.r,l(-
<br />caauauqu9xL.[uulNclcl:NclIn$c},yrrn rndcr Fndr! .1 Nrjxry th r,u.hacon{ru.ibnhndirssscrcyiorrhcncrlornuh-'corrhc*orkr.rwhi.hlhtlEirnilis
<br />i$ucd (Scc..109?. Civ C )
<br />t ndcls Addrcss
<br />-
<br />i.ttllqrNlMg,rlait.Il0tt
<br />lhlnhvrltn,undrrn trrlrvof trrjrr\ o cof rhrn)ll(rvi'ign..hrnrnr\
<br />Dc nnirlon Icmir\ Asbc!.s N.rilicxr i,u l:sdn' l Rcsu hr i,trr (l irlc 40. l'xa6)
<br />Rcqtrtrc t-.[d !l Nolii].riI
<br />I.c ifyrhd nr f.dcful icllldi,)trs rc8rdr! id{(o\r. n,ulnrc trorrpflicahlclo rhnl]lojecr
<br />l.cniryrhnr I luvc rc&l r[is0pflic0lion ffilsrrcth rhc h,vc inlbnnrrnr nc.n.d I,rd.trr.r\.'nJsrihLnr.r.hhner. irr!ir'F!on{ru('1aL*e!\.rch}JUrh"'vc.,,1.crrJr
<br />,'h{c 'ft r[ lf" r.d] n, .r..1r t'dr,', {./l /, J/
<br />rppti.,nr.r rsenrsrAnnrum X ->{ -L u;' - ,
<br />pcmrrrecmne,pri ,,D( -t o, '11'/4 '-=11 I .<
<br />aCre ro orpll wirh allCilyand Counry
<br />iver otlhh Cny,nd Coun'yro enicr ulx,n rtE
<br />al.-.7Q-tQ
<br />Site-Work
<br />Underqround ra/R/* :e.;zDzz*'o', ./
<br />Pole Bases ,fl" llt r''6*1oflr6--t6/
<br />Light Standards "L
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER td,tllr t "41/lBrvtk t0/
<br />Translormers t
<br />-'t'
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Faclory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Bouoh
<br />Ceilings (T-Bar Rouoh)
<br />lt/eter Release
<br />Rouqh lL-lt-16 l5-(*a /e) ^I lt{ ^Service IVleter 1U.^Jttt .)f.'
<br />FINAL 2,o
<br />Notes, Remarks, Etc
<br />-)
<br />DATE
<br />r hz tE?kA
<br />l. ,s owmr or rhc popcny. or my .mploy..s silh wag.s as rhci sok conlrns.l ion- will do llr sork ad rhe {t*re h rcr
<br />inrc .{l or olIcred for slc (SN 7044. Busine$ ud ttofcsions Codcr Th. G)nraclrnt Liensc Llw des trot .ptly lo !n owmr of
<br />lh.Irenny who t{ilds or irq'mwsltEmn. and wto de\ sKh wo himr.lf.r h.r€lf o. rhmuAh hr or hcr ovn cmrlt,yecs.
<br />providcd lh.r sx.h inEovcnrnh nrc mri cndcd orolt rrn for sL.lf- hoevcr rhc buaui.g or ir9(\sEnl isY,hwilhinonc )ttr
<br />of.or!,hrio lh. Owner Builllf will haw dE hlnL! or pmring thd lE or sh. dil mr buib or intmir ttc i'mFny r.r rrE purp$ or
<br />l. rr owftr of rhc lftp.ny. an cx.lusiwly contudnrS wiih li.cnsed co lr0dos h connrud rhc proF.r (sc.. 70t r, 8u\j.c$
<br />0 i ftofcsbn Code: The Conrrdoi\ Liccnt l iw dds nor apply !o m ownc. of pmFny wno huilds o! improv.! rhcrq'n,
<br />rtrd wlm.ontm.sr(trsuchpr+dsvirhaConrEdo(rltcnscdruralnrrorhcConrdcroisLi.cns.l-0w).
<br />_l r'ncx. rll undcr Sc.rion ,B.&P.C lor this rctrson
<br />D.l.: Own .:
<br />.It "L.--'t
<br />I
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