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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWN'R AUILDER DELCARATION
<br />I hcrcby rnd utrds prnalry or Frjury rlur I m cxcmpl fn n rhc Conrmcros Licetr* li* lor rhc rrrlowinS rca$n (Scc.7oll 5
<br />axsir.* rld Pr.rc$ion Codc): Any Cily or Counry uhth rcquires s Frhir k, ..n{rucr. alrcr, mprorc. &mnnh or tnir rny
<br />(fldurc, frbr lo irs isuancc. 6ho rcquncs rhe aptltanr for such Fnnn b fih a si8ncd tulcm lhlr hc or shc k lic.nscd ,uNMl
<br />lo lhc p.ovisions ol rlt C.nr,actr's Li.cn*d L.r (Chaprcr 9, Co.mr.cing wilh S.cri.n 7(Xx) ol Divtion :l ofthc Blsincss rnd
<br />Protc{sions c(ldc ) .r rhnr h.or \hc iscxcnpt lhcrct'rorn ond rhc blsn for lhc ollescd crc4)riotr Atry vnnalionofSccrion?0:11.5 br!.,
<br />aff'li.rnrr(tr!lcrnirsuhjcrFlhc!0plicanrtorcivilpcoslryofnorixtrcihdtrfivchundreddollor!($500)
<br />I. as ownM or rh. ,mFny. or m, cnployes *nh woscs ff rh.t slc s,nP.n{rirn, will d. lhc *ori si lhc .rndm is mr
<br />inrcndcn or ofieE-d ttr {k (Sa.7014, Busiftsc and Pmr.ssions Codc Thc C.ntEclois Liccne t3w &B no! 0rPIy to 0n owcr o,
<br />rhc pn,lrn, *tu b{ikis or inrrmEs rheEn. ud who des qch m* himclror hc*clror lhouBh ht or hct o*ncmployc.s,
<br />tn,vidcd rhd su.h inlllbmnh @ ml i.rcnd.d d oficrlrd fo. \!L lt hosev.r. rte boildinS or idlpmttrm is srB snhin onc y@
<br />olonrkrhn. rhc O*ncr Buildcr will h,v. rh. burdcn ofproving dd hc or shc dil mr toild or ir{,ovc rr pmFiy lor lhc puqns of
<br />l. ro*nrrofrhcrn)pcdy, a cx.lurivcly conticri0! sirh li.cn\cd.o.trldrst, (1,nitu.r rh. r.J.1_r (Scc ?0.l4.lnxtm$
<br />anl Piol|sinr Codc Th.(innr!ck, s l-icdn\c l-a$ {n'c\ nor 3rplyt, nnoamr.ltrol'cny*ho l,ulldl or imrn,v$ rhc.cor,
<br />rtrd trho cont t ritr s!.h rmirrs wirh a Cbtrr,ch( s) licctr{d luNunr ro rhc Contrktr\ L{cns Law).
<br />I uDcrcnrll trndcr Scclnnr-, B &P.C iorrhnrcrson
<br />D.le:- OBrer:
<br />WORKERi' CO,tlPEiSAT()N
<br />DECLASAIION
<br />I hcrcby llttmundcr pcnolryoaFrjuryonc ofrhc aolbqn'E decld,rio.\:
<br />I h{vc xl will nEint0in r Ccnificurc of Cooscnr k, Sclalnsrrc fd *orkns mmFcnslliotr. as l,ovilcd lor by Scctn,n lTtro ol rhc
<br />Lalxtr Ckl.. tor rhr p.rromEncc ofthc wort lhr which thc pcnnit is issx.d
<br />Ihavc.nd*illnDinr.in{orkcrs'.on[.nsaridoinruratuc.r* rcquncd by SEl io. ]1700 oa rhc Litnn cl c, aor the Dcrfornumc ol
<br />tcnnir i\ i$dc Mt sork.r! .(nnpci\d.oi sur n.u.rnicr md Bnicy ru rbd tc
<br />I ccnrrythar inlhc pc oflMnccorrhewoIkrq*hkhrhnr.rnirisi\sucd.lshlllnolcmPloyanyp.ronn'a.ymanncr
<br />v, 6 ro hccom suhj{r ro lhc workcn comt n\dion ldws orculbrni{.lnd ssEc lhsl ifI rh(,uld bcconE sublcd tolhc
<br />wolkcn'compcnrarionpn$n,n\orsern 1700 or rh. tjtb. codc. I rh.ll. iorl hsil h L$ rply wirh rhos ,mvGions..
<br />WARNING F,ilurc ro surc workcm'convEns0'ion s,vcro8c is unuwful. utu]\hill subitr !n cmploycr lo simiml FMhts tM
<br />rilil firo\ trt k, ofc hu drc rh.u\rnd d.llrr (SlU).(Xx)). ir ixldiri,nr b rh..o{nsutDn. dlnu8cs as povidcd for rh.
<br />S<rion.1076.trhc ltrbo, C&lc. inlcrc( 3"d otlorrcy s les.
<br />fin{11 ?010
<br />!.2r(I.jtt -roN
<br />IhcNhyrflirrundcrpcmltyolpc.jurrrhrrIroliccnaitndcrpmvisionolChnflci9(co,mncingwirhS..tor7fi)0)oIDivision:l
<br />.i rhe Bu\incs\ a Ptufcssior\(i)dc, drd my liccnsc i\ lulllarcc<lL.r
<br />?
<br />".,.J!$ L]-I #l
<br />CONSTRUCTION LE'IUN(; A(iENCY
<br />I hckby rmnn undcr JEnrlry oi !,crjrry rhlr rherc h ! consmdion lcnding r8rtrcy ior lh€ Pcrfomncc .r rh. wo.k for qhich thn lErnil ir
<br />isslcd (Scc 3097, Civ. C.).
<br />-lccnify
<br />rhri rhc t d.ral rc8llations rc8udin8 osbe(o\rcmul lrc Rn 4plicrhh lo rhis Poi6t
<br />.A ccnny that I h.vc icad rhn $!li.ari,,naJrl{r!crharrhxatsvc nrfonurion is corer I lsc t, convly wnh rll City and Counly
<br />i,rdirhrcs nd Skr. Lr$r.cLii'rsIo huildi
<br />xbo!! mc rn)n.d lr,Jrnt tu i,nNclior
<br />Appll.Bnl or &€trl Sismlur
<br />Prmrilft nnnF ( Drinl):
<br />"'r ii(l fi'1""15,,,t'.
<br />!r '- I /
<br />l)ole
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Founlains
<br />Signs (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Bualdinq
<br />Bondinq / Groundino / UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Faclory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinos (Hard & Solfit Rouqh
<br />Ceilings (T-Bar Rough)
<br />lVeter Release
<br />Rough ra/i,t /1,6 a\ffi
<br />Service ltileter
<br />FINAL ? /t-/r *os tol
<br />Notes, Remarks, Etc
<br />Under Slab / Floor
<br />ATELICANfI,IECI.AAAIIAN
<br />I hdl.6ylllimlndf pctr,lry oitcrjury onc ollhc Iollowins d(l ation\:
<br />Dcnolilio. Pcrnrih-AstEsros Norificario. Fcd...l ReEU lal ions (Til lc 40, Psl6)
<br />-Rcquircd
<br />Lcrrcr of N.nifi€rion
<br />4-
<br />F
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