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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE tD/stG.COMMENTS
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lite Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soflit Rough
<br />Ceilings (T-Bar Rough)
<br />lvleter Release
<br />I ,1 ,/ 06 DO
<br />Rough tl n,
<br />=1bService lvleter
<br />FINAL '-qz{y'tI >\T{
<br />Notes, Remarks, Etc.
<br />OWNER BUILDER DEI,C]ARATION
<br />I herchy alrrm oft.icr n ulry ol p.rjuy rh, I d.rcnpr {om lnc Con{mck,N Litnr L3s ntr rh. l,llowhr rca$; (S." /o]li
<br />Brsioes lnl Pn,L$irn C*r.)r Ahy Ciry or Cou{, whrh Equncs r rrhit to onsrtul. allcr. ihpove, d.mnM or rcI'af my
<br />$rucrurc, Fsrro ns ssuec. rho Equn s tlr ap,,lrlnr lorsuchFmir b llL r r,gnc,l slalemni rhir hcorshc n lccnc,l ll!nu!.r
<br />b rhc ln,vsions ot lrf, ContR.kn s Li.cnrcJ tlw (Ch.plcr 9. Commercins wirh Scctn,n 7000 or Diviiion I of rhe Businc$ and
<br />Pmtcskns Cujc) or rh.l hcorrh. neichpl lhecfrom lnd lte h{ri fot rh. ,ll.!.d .x.m0ri(r. AnyvnnatiorolSccri,n'70.11 t hy!n,
<br />pplica nr a l€mir 6jak rh. i0plicanr ro a civil proalry or tur mr. thr liv. hundEi Jolles (15u)).
<br />l. is .wncr of thc ,ruIlclly, {! nry cmpLr.cr wirh waScs {s llEir n)h comr.n\arbh, will do thc w)rk od rhe nturm i\ M
<br />i' cBl.d or ofti(d r{, srlc (5&.7044, Buro.$ dd turarsr)ns CGlc: l h. o)nrractq s l-icn!. lrw Jtur not rptly h o*mr I
<br />lhcpNFny wio t'u,Lts or irlp ,ks rh€s,n. url sho &s srh k rt hih$lf r h.rslf ot rhnn,Sh hR or hcr own $rLy.cs.
<br />pbldcd rhat such iml()rcmnc N nor d.ndol oroltcEri li,r sdlc. lli h'wcw, rh.hu lin8 or inlnwmnr is slJ wirhio oN ra
<br />ol d'mthr ion, rhc Ornc, Buildcr will hav. rhc hurdcn uf p$ving rhlr h. or \hc dil mt huill o, itr{trovc lllc I^,Fny lbr ltr Furlr)$ ol
<br />_1. r\ Dwn.ro, rh. tbp.n!, rN.rclusivcly.onradda w[h lrccnsc,j conrracroN b con(tucr rlt ln)iccr (Scc.7O4a. Bunnc$
<br />lBt lllrisin Colcr Thc Contacro.r I-iL.nsc La* d*\ nor aprly h,nowncr olpopcrry wh, btrilJ. or inln)vcs rh.F)n.
<br />lnd wh. co.rn.ts ror such t ojccl s w'lh a Conrr.cld, lrcnscd pu^lur (' rh. conri.ntri Li.cnrc Law)
<br />loe tI
<br />1!98[LtsS]1-.(]r1rEr5i!t!tD
<br />t)!.(1. \l{ \ U()\
<br />i,lrn rnd.. Nnili!.1 t^.^!jury.n. ol rh. n)li)wng Jc.lx'r(nn
<br />-lhav.drlwillmi
<br />dr a Ccnraralc otclrEnl o Scll-lnsurc Lr wortcr' ()hp.nsdrn,n. ,! pruvilcd fot bySeri,,n.l?00 ol ihc
<br />l-atxr Cotl., lar rhc Frn,mMcc ot rhc wort lnr whkh rh. lcmx s rrucd.
<br />I hrvc rrd *nln.intlin workcrs .omFnsalion insur!ftc. as rcquiot bySdrir.l70O.l rhc htxtr Co!c, ntrrhc Friomunc. of
<br />thc wo* tbrwhrhthn Fmills nsu.n. Myworkers com0ensarn,n m{snc..ri.r arxl Ftlry numbct m:t Y*11 f r-
<br />Poli.y Numb€r:-EqtEs
<br />_l .cn ily rhar in rlr Frton:uncc .f rlr. work lor sh(h rhi{r.rnril r hsrc,l,I shallnor emtbyrn} p.^on in lny ntinncr
<br />$ .r k, kscorE subrcr b rhe wo*.n' comp.nsarn,n kws of Cakbma. anrt ige (har if I $oukl h..ome suhrcur t, th.
<br />mrk s' ..mrns.t ion l,$!trionr oI S(liotr .l?00 ol rhc ljlnr Col.. I \hil. bdhwnh L$n ly *ith lh{c lrovnnrs.
<br />WARNIN(;I Faihr. b *xrc wik.rs onlJl.ns oh cov.nlc 1s utrlrwtul. anJ rhau subF.r an.ntloy.r lo crinr.l pctrrlr$ {nd
<br />.'v'l i,ncr W ro oft tundmd lhous.nl do,lrs (Sloo,ux)), !n ddnion b rhc.on 6f.onFns.tion. dtm8.s r
<br />If,br Cilc, intcrcsr.nl irlomy s l.cs (
<br />tlrElsEl{oNr! craBDt:cl,aIttlIoN
<br />I heEhy rlnnundcr pcmlryolpcrjury rhd I dh lictrsd undcr lft)visrn orCilptcr I (.on,nEncia3 wnh S.crdn 7UX,) ol trlvis.n.l
<br />ol thc llurircs 3nJ PDnsionsCodc. sd nyl'c.nk n
<br />'n
<br />full ldcc rd cfl$r
<br />COIIIAIJ!:II{INIENDIIC.&AENCI
<br />!,Itrm undcr Fmlty ol Frjury thri rhcrc h a crrn{ndh LnJins agcky lar rh. Pcrli.mrcc .t thc Rnk rbr wh{h rhis Fm il
<br />r!u.J (Se.. .1097, Civ. C.).
<br />thdeis Nam.r
<br />-^t&!t Nllliel Sarlo!
<br />I h.rr*!y.lunn u crncnrlry.r pcriuryonc or rhc hl1,)wrnp Jc. bnr i,,n\:
<br />Dchohron Pcrh s \h.no\ N.rli.{rn hd.mlRcluhrnn\ (lIL.l0. P..r6)
<br />R.rturcd h(rrol Nor lr&.n
<br />_l rtd,ii rh,r rh. r.d.ral rcSuLr ion\ rc!&nhr nh.rdsamv.larc mlramlrrblc io rhttn*rr
<br />l.c,rrly rhr I hiv. turJ rlsrml
<br />onntrrnr.\ xn(lsrrrc l_is\ rcbr,n! !,
<br />iuh.n dd nirc rhI rh. rtl,lc 'nntrn
<br />(rreon.cl lr3rceloconrtlywi(hallC'tyindC nrly
<br />")"'ii/irl{),2
<br />atx,vc nFnrrlrl nn)pcny hr insnc!
<br />AppliMnt.rAgent Sigtr{lurc
<br />p-,lle EmrDrinlr:
<br />Site-Work
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