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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS ID/SIG.COMMENTS O*na-Buildcr D..ldlion
<br />I h.rcby.rilm u.<br pdalry of p..lur, tn.t I m.xdpl aom rnc Contrdd' Lien* La* lor ti. follwin8 Bo Ge TOll 5 BNinB
<br />dd Prcf6sion Cod.) Any Ciry d Counq which Equir6 a p.mn lo €olrruc! altd. ioprovc &nolish or rcp{r My sruciur., pnd @ iB
<br />issumcq .lso r.qun6 thc applicer lor such p.mi lo filc a siglcd il'r@at rhlt h! o sn. is limscd punu r b lh. Fovisios of dr
<br />ConFador's Lica!.d rle (Cnapd 9, C.mmmcing wiln Sdion 7000 of Division I 01lh. B6ine &d Prcfeiont Cod.) q tnd h. c
<br />sh. is .xmpr rh@arom ud lllc bais fo lhc rll.g.d ddptioi any violalion of S.clion ?03 L5 by uy applicul for a pqrfi subj@c fi.
<br />+pli6r lo acivilpcnshy ofncn norc Oe iv. hundrcddoll6 (t500)
<br />_I, s oM6 oa fic p.opny, q my cmployG wi$ vagB a thcir sl. cmFn {ion, will do th. work sd ttc slructrc ii not irhd.d
<br />or off.rcd fG sol. ( Scc ?0a4, B6in6 sd Prof.$i6s Cod. Ih. Confuclor's Licd!. L5* do6 not lpply lo e oMa ol $c pop.iy
<br />eh6 buil& or imFov6 $crcn, sd who dG swh wort hirelf tr hddl d d@d hk or hd @n f,ploycs, prcvid.d lllar 3uch
<br />inprovmoll u. not inrod.d { off.En for srl. Ii h6w.v6,lhc buildi.S o. inprcvddl is sld wilhin on. ycd of conpl€ton, lhc
<br />Omd-Builda sill hav. !h. burdd of proving lnar h. d sh. not blild or imp.ov. as th€ purpcc of $1.)
<br />_I. 6 ownd oatn. prcp.rty, m cxcl$iv.ly conF&tins wilh lic.ns.d conn-&to6 to.dsEud 6c Drcjat ( S.c 7044, Bsines ud
<br />Profssion Coda Tnc Co.tacrut Liens€ Llw do.s nollpply to e owd olprop.n, who buil& d inprov.s lh@on , dd who
<br />€o@B f6 such poj.cB sirh r Coin&ro(, li6ed px6udl 10 lhc C@hcrort Lic..* llw )
<br />_l m cx.mpt undcrsccnon ,B & PC rd rhis E6on
<br />WON'(ERS COMPENSATION DECLARATTON
<br />I h.r.by altm urdcr pflalty ol pqjury onc ol thc lollowing dele,,lions:
<br />_l havc &d *ill hai.rain a Ccnifidc oa Cosot to Sclfinsft for wtrt6' compnsalion, a poyid.d for by Srclis 3700 oft.
<br />Labd Codc, for lhc p.rfmo@ of rhc worL for qhich rhc D.mn ii issu.d
<br />I havcdd *ill mrin6if, *dk6 conpsEarion if,s!tuc., 6 rcqutcd by S.clion l?00 of th. kbor Codc, lot $c p.rfmec. of th.
<br />work lor ehich ihis Fnir i! issu.d My workd' cmFB.rion insumc. csi.r md policy numb.r uc
<br />Policy Numb.r: Eipird
<br />,:.",..,,"r.*,,i,*,,"
<br />nor b. comDl.t diflhcpcrmn is forOn.hundlcddollss lll00) or
<br />rhc p.rfomue of thc qork fs which lhisPmilis issu.d,I sh
<br />tE wortcB ' .omp.N.lid las ofciliaomir, od aSrG lnar i
<br />onsolS.ction3T00ofrhc Labor Codc, I shall
<br />WARNING Failurc ro r(urc worl6' compcnsarion &.mployer tooimin, p.naltlB d civil
<br />fin6 up to @c hui<lr.d $ousd dolla (l10o,000),in iddnjoo b rhc sr or
<br />$. Libo, Cod.. intGr d atomcy\ fes
<br />rLm.e6 a provid.d for d. Selio. 1076 ol
<br />t.tctNs[p coN-t t^alot{s DI]ct-aRAl loN
<br />I hcrcby rlnm und.r p.nrhy of pdjury thlt I h licds.d und.r povision of Chaplq 9 (
<br />thc Businds Md Prcfdions Cod., md my lic.ns. is in full forc. dd.fcct.
<br />wi$ Selion ?000) ofDivi
<br />4-t(
<br />I hftby amm udd Fnalty of Fjury lh.t th@ i! . oislrucrid l.nding agdcy fd ln.
<br />isu.d (Sft. 3097, Civ. C.).
<br />ofrhc *6k for qhich this p.mn t
<br />AIIUCAXI]iD9CIAAAI,ION
<br />Ddoltion P.miE-Arb6r6 Noifiadd Fcd.rll RcBuladds (Ttlc 10. Pdr 6)
<br />_ R.qut.d L.nr oiNolificatiM
<br />I cg{Y-lnar $c rcd.El rcsul
<br />Z I c.n,fy rh l har.r.ad$is
<br />'ord'nr.6 md srat. t,wr Elari
<br />cmpl,wnhallCity dCounry
<br />Ciiy ad Couhry to 6!* lpon lh.
<br />abovc m.nrioncd prop.ny lor insp.ction purros6
<br />46 hct
<br />eoL
<br />Site-Work
<br />Underground
<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 />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torquing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rough
<br />Ceilings (T-Bar Rough)
<br />Meter Release graf I I\E.L'
<br />Rough rrD lrnro
<br />Service Meter
<br />FINAL SAMC 8-43, 2 90, ss6, 667
<br />Notes, Remarks, Elc.
<br />DATE
<br />Ln,L.'3 A,tdn*, _
<br />F
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