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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE tD/stG.COMMENTS OWNER BUILDER DEI,CANATION
<br />I hsety a,Itrm und6 paahy of p.rjury Ihal I M ncmpt fmm Ihc Conmdo6 Li.d* Lrw aor rh. follo$in8 r.Mn (Sd 701 I s
<br />Busin6s dd Proraion Cod.): Any Cny or Counry \hi.n relund . tnnir ro co.srucl. ah6. nnpmve doolish oL r.p6n y
<br />sn'.nft. prior ro irs isrec.. also r.quiG ifi. applicanr for sNh Fmir to lilc a sisn.d starod rhd h. or sh. i! li.dEdl pumsr
<br />ro rhc Fo!is!o6 orrh. Contr.cror's l-i.en*d t * {Chaprd 9. Cdm,r.ncing Nilh Sedion ?000 oi Ditision I ofth. Busind od
<br />Proa.si.'ns Cod.) or thar h.orshe is.rmpt rhaelromand rhc b6sis aor lh€all.sedcr€mplion. Any violalio. ofsdtion 70.1I 5brany
<br />applicsnl lor a pmil subjNlslhe applicant to acivilpcnahyolnol mor€lhan fiv. hu.dr.d dolltrs ($500).
<br />L as o$nn of rlE prcr.ny, or my mployG wiih waSB s nrcir el. comp€nsar ion. will do rht *ort ad thc sltod@ is .or
<br />inlo cd orolld.d lorelc(Sa 7044. A6ins and Pretsions Cdq I'heCodradors Li.tuc L!\v &6 not ipply lo e ownd of
<br />rh. proF.dy Nho buildB or i,nr,o\6 $eon. dd $no d.6 su.h rvort hims€llor n6daor rhrcush his orid oM €hployG,
<br />,mvid.d thar such inFovddrs ft nor imdrld, or or6.d ft)r sk ll ho*6 6. $. f(ildiry or im[,or.1cl is $ld vhhin nn. )sr
<br />ofcompkion. lhc Osr6 Build6 Nill hatr lh. tu(k' of p.orins lhd h. or sh. dxj m' build ot inqm\. fit Flpcly aor lh€ p{rros of
<br />I, s o$.r oflh. p6trty, d d.lusiv.ly .onta.rinf, $ nh li..Nd .oitacrou
<br />'o
<br />coNtrud
<br />'h. F!r< lse. 70.1,1, Bunn<
<br />and l\tasion Cod€r Thc aontra.rois Lic€me Las do6 not applylo mowns orproFny rvho builds or improva th.ron,
<br />and {ho contacts ror n'ch rrciel' vith a Co.rE(o4s) li.chs.d puuud lo nE Conlractors Licm* Lav)
<br />lrrDcxcn,|1 trn(1.' Sdntr I & I'(' l.' (hisre8on.
<br />Drte orn.r:
<br />\roRl(FLs.coMPENSA-idii
<br />DECI.AAAI!g!
<br />I h@6y amm und6 pen,lryofpajuryon.ofrhe aollo$inr. deldarioB:
<br />I hav. od *ill mainrain . C.nificar. ofco's6i ro S.ltunsurc aor qork6 compstsdion. s pmvid.d lor by Sclion 1700 ofrh.
<br />Labor Cod., lor rh. pdfot@.. oarn *ort aor which rn Fnnn is isu.d.
<br />\2fi-N. and Nill mainlrin wortm comFnsaio. i.sudnc., d r.qut d by S*rion -1700 offic l:60r Cod.. for th. psfomoc. or
<br />lh€ wo,k ior which lnh pmir is isu.d. My workft comp.nsarion insurdce cario ad po,icy nlmbd ml
<br />"*
<br />Poh.y N,,nb-, eggS:Q\q,eo a- *** (, (' I lr
<br />\
<br />I cdiry rhar i. rhc pahr@c. of th. $!rl for whth rhB Fnir 's
<br />irsu.d. I sh.ll nor 6ploy my pEMi in dy nd(6
<br />$ 6 to be.om subjel to th. *ortd' comFNriotr hB olc.liaomir ad asrE $ar ifl should h.on'. rubjer ro lh.
<br />BorI6 @npos(ion povirioN ofsetio. l?00 of lh. tibor Cod.. I shdl, fonhqiih comply rith lhos povisioa..
<br />WAIrNINC faihrc ro rcurc work€rs compcnsalion co\salc s unlaqful, dd sh.ll subj.d an @ploytr to diminal psa[is and
<br />civil finesuptoon.hu red thousand doll6 ($100,000). in addnion totheco$ oacompensalion. donoses N ltrovided forlhc
<br />r,"",t/a/11-6 v <a^<s-\J'.v\ frpi+
<br />{I!!!NIL(I)I]&1CIoB
<br />!.DeLr!8![O!
<br />I hd.by ortrD und6 pcnah, of pdjury thst I m lic€a$d und6 pro\ ision orchapl6I (co6'nd.ins $irh s-rio.7000) ofDivision l
<br />ol rhcB6insdd Proasiors Cod.. ed my lic.N. is in tull torc. ad eiIEr
<br />ri.."* cl"*, lL :\Q l.(e\. \, 'nbn' \C\'LqL'!\H ,( ,-=.o'." Grdct
<br />I h@by arm !nd- p.nah, of pajury thrr rh6. ii a coNrrucrion kfldif,8 as6cy for lhc Ffolrmcc of rt. worl lor whi.h lhir F,nn i
<br />isucd (s6. 3097. civ c.)
<br />A.EIIICANLDECIAAAIIQN
<br />I lEd,t ailinn unde! penalty olperur) onc oflt.lolloNins dsluations:
<br />o.molirnnPenil. Asb6r.s Noti6..'io. I'cddal Rcluldions(Titl.40. P 16)
<br />Rrqtrred L.nLr of Norii. i.n
<br />]jnri rhd ! h. f.dcral l+ulaoo6 r.se drnB abGros rmo\ trl e. nol appl'.abkro rha proJfr
<br />Vi cdrry rhal I ha\. @d rhB appli(ar'o. ad srar.lhr rh. ahv. i.aomirion is.oncl.I ngrd ro complywilhsll Cilyand Counly
<br />odi',ancsandSrare La\$ daxn! n, luildi ! consrrucrion. tudh.Rhy.ur icprBmrarivs oflhis Cil!'nnd Counlyto mrs upon rhe
<br />abov€ mstion€d pBp.ny lor inspcclion pupos6.
<br />ApprienrorAs€trrsisnoru.e: \l,a*:
<br />p"^i,*."."tp;"r ts:t-N-]A e6p-oR t t"
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rough)
<br />Meter Release
<br />Rough
<br />Service hileter / /FINAL , /t1/loS-iz<alrLtl ,{
<br />Notes, Rematks, dtc
<br />Pole Bases
<br />s..!$n 1016 ol(lrc l:htraodc. i, c,.n3ndarnmcv slds
<br />ro
<br />l-cn{ld s Ad&6:
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