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ELECTRICAL.INSPEGTOR RECORD
<br />ID/SIG COMMENTSAPPROVALSDATE
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondinq / Groundino / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilinqs (T-Bar Rouoh)
<br />Meter Release
<br />Rough
<br />Service Meter
<br />L"*91FINALI2ADtl""oo
<br />Notes, Remarks, Etc I
<br />I h6."r( ,6nn u.dr Fnally ot p6jur,v lnal , on crflpl f.om lh. Conlra.ro6 Li.ds. LaN ior lh. follovirs laeo (Sd.701 1 .5
<br />Busi.es snd Prof6sion (ode): Any Cily o. Counly shich r€quns . lrnnt ro conslrucl. alt6. improvc d.nolish or re!6n ay
<br />srruclLtrc, prior to s isuanc.. aho r.qut6 rh. aNlicmr for such Frrn to file a sisacd slalmd! rh.l he or sn. is lics.d tmuel
<br />to rhe povhions of lhe Conrra.rois t,ic.nsed tn* (Chafld r, Comm.n.inS \rnh Sdion ?000 oi Division :l oflh. Busi.4 dd
<br />Itolesions Code)orrhd h.orsh.i5 crcdfl rh6.fro,n Md rhe bsis lorlhcall.scd€x@plion nyliolarionofsdionT0ll5byany
<br />applica roraptrnsubt{krh.,pplicanlroacivilpenallyofnotnr.ethanfivehundreddollds($t00)
<br />L N ownq ofrn. prcpcny. or my eoploy6 {irh wag6 a rheir $l. .o,npNlion. sill do thc rvort od lh. slru.rd. b nol
<br />intodel oron6.d for el. (56 7()44. Busins ed Proasions Cod€ lhc Contraclois Ltd* t$ &6 not aPPly io m orvnd of
<br />ilrrmpdly who bnil& or implo!6thseo. d $ho do6 such \wrk hids.lf or hds.lf or Ihrotrsh his o! hd own mploy6,
<br />!trovid.drhar such irym\ dnars se nol inlad.d or onqsl aor slc. Ii no\ 6's. rhc blildin! or tr4rovdndr ir $h wnhi. on. yat
<br />orcomderirn, t Osad Buildd will h,v. ih. hir&r ofprovin8 lhd nc or sfic did ml build or ihpror. rh. ln)pd, tur rhe p!4!s oa
<br />L ac o*nd ofrh. F.p.ny. m€rclusn€lyconlradin-! $ilh liceBcd co'nta.h* ro .otuitud rh. Fojd (S4. ?014. B6ins
<br />aad Pmlsion Cod€: 'rhe Conrracrort Li.c.s. La* doc.or applylo n owr6 oaprop<ny sho builds or inpro!6 rh&s..
<br />and $ho conaads for $.h prcjets N naCo mclo(s) licoscd l'ursua torhc cont.dor's Licns. Low).
<br />I dn.rc,npi undftSdrion .B &l'C lor rhisreen
<br />Dllr: OFm.
<br />loB(EStt(2ruErsa-M!
<br />rrE(ta8drlo!
<br />I h&.by,fiinn unds p.nalryof pcjulyoneof rlE lollowin8 dclaralions:
<br />I hav. ddNiiltuim,i. ac.nili.ar. ofco,s roS.lfinsur.aortrorlss.oopo6aion.a pmvil.d aor bySdion 1700 ofth€
<br />Labor Codc. lor thc Flolr@.c oa rh. rvork aor \ehi.h rh. pnnit ii istral.
<br />I haveand willn.intain sorkqi co ,p€nsalion insuraoce. ar r.qun d 6ySdion 17(JoollhcLabotCodc forrhepfiLmMcc6f
<br />rhe \ork fo, $hich lhis psnir is isu€d. My *'0116' .oftp<sai iod iBur.ncc cMid adlElicynu.,hs dc:
<br />dll RluE < .4aS zo.
<br />',,,,,,'.", A/t z,az+6a ,\fi.\,1ry'"
<br />I .cnifyrha( ii rh. peiormrnc€ ofih. worl for \rhich lhh prmit is issucd- I shall n.l dploy any pd$n in any manrcr
<br />e 6 to b€om€ suqat to rh€ *ork* NmFerion lars oac.lilomi.. dd .srE rhal il I should b.{o'i€ sub(r
<br />'o 'h.{0116 comp€Nrion pmvisrd oas..rion I700.frh. hbor Cod( I sh.ll. f.nh\ ilh onrply wilh rho* p@virions
<br />WARNING: Failui. ro sr. Norks comp€nerion co\en8e is urlaw
<br />-.-
<br />.hall srbjer M dploF lo aiminal FEhi6 dd
<br />osr of.onFnelion. &hag6 6 provid.n tor lh€cnil fii.s up ro d e htrndr.d rhousond dollars (Sl0o.trLU). in
<br />6n 1076ollh. titn (h&. inrB6r and allonry\ fe6.
<br />/ '3 - 2-.)
<br />I hmby amm unds r6ah, of pdj!ry rhar I u licmsl undd Folisio. ofChaplr9lconmdci.g trnh Sd,ion 7000) ofDnision 1
<br />of lhe Busins and Prol6io6 Codc, and oy licd* is in aull lorc. dd .rer
<br />r,.e*c(ris e-20
<br />r", /:J-2a
<br />( (rNslRU( fl()N t,uNDtN(; ,\(;t.tN( l
<br />I nftby srm u.dr Fflahy of pojury lhlt thsc b a @Bltuclion ldding ago., lor Ih. pdfommcc oflhc wort h, \'hich rhi. pqoi b
<br />isuct (Sc 1097. Civ. C.).
<br />AXSI=ICAILIECIABAIIO!
<br />I hdrry 8rm uid6 Fnally of psjury onc of lh€ follo*in8 d(lMliotu:
<br />D€mohion Pmil'Asb6los Notiicatio. Fcddal R.guLliom (Till.40. P0n6)
<br />-R.quiEd
<br />Ld&roaNoli6cdion
<br />I ctn ily ihsl rh€ ledEal rcsulari.m resddins sb6ttu rdno\ ai arc nor .pplic.lic lo rhis pnje.l
<br />p.-",*,rhar rh€ above infnmrrion ts..ftol I alra Io comply vilt all Cily and Counly
<br />cli.n. md hs€by aurhorn. Ern6drni!6 o f this cily ed County to dl6 upon lh.
<br />alrnc $$rii]nei p'opcny ror rs
<br />,\Dpli(trtrr or Asqr Sisnrqrc
<br />Pcrr ilN n.nc (nrinl ):
<br />,),,, /'?-?.-
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