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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AULDFJR DEI,CARATION
<br />I hcrc$y silrm undcr pcnalry or p.rjtrry rhar I M crcnfr fo.r rh. conta.k,R Liccns tjw rbr rhc ,olloting rcR,n ($..701 1 .5
<br />Burin.is and Pmrcsn,. Codc): Any City or Cou.ry *hkh r.quncs 0 Fa lil ro consrrucr, ancr. anProre. dctdnh or tIEn !n,
<br />nnclurc, riorto irs hsuiftc. al$ rcquircs rhcappli.ntrt lor suchFrmir to filcfl signed (at nenr rhd hcorshc is liccnscd lursurnr ,
<br />ro thc pmvnions of lhc a,nta.ror's Lifttrscd Lr* (Chall& 9. C.mftn.nrg wnh Scction 7lX)0 of Division I ofdr Busirl.s ind
<br />Pior.lst,ns Codcl.r thnr h. or shc is crcmrl thcrcfr(,m !M thc btrs's for lhc allescd crcnplion Any liolarion of sdion 7011.5 hyany
<br />rpplicad for tr pcmi' slbjeh lhc applicanl ro !civilFnillyofnol norerh,n 6v. hundr.d dollo (S5(x))
<br />l-r\ownc.orrhcpfl,r.dy,ornlvcrpkJy.cswirh*r!.\a\lhcirq,lc.o.r&ns0lion.*illdoih.*ork3rndrnr*rmi.,hi
<br />n cM.d or ofltrcd for lnk ( S1. 7(}{,l. Busiflc$ ind Prolisiotrs Cdcr 'l hc (i,nklctois t-i.cn\c l-rt d.cs not lplly tu roFncroi
<br />rhc pDpcny $h.buildsor imprcvcs lhson. mdwlr d.cs such $ork hnns.lfor hcr!.lforrhronghhiror hcrowncmpk'y&s,
<br />nnrvldL\l rhrr nRh i,Dttrovcnrnh uc not inrcndcd ordlta{ Lr srlL lr: fi,wcvci rhc huilli$ or i troh rnr k mllairhinonc )tJr
<br />.f.onlPlcrion. rhcO*nd Blikl$ willhrvc rltr bnrdci ot ptuvnE thar hc or shc did nol huild or inurorc rhc pmFny f.r rh. purtrFc of
<br />I. N.qrcrofthc |)lo,Eny. ancxclusivcly cofiactine wnh liccnscd co.rftclor\ lo con{n'cr rhc piorc.i (Scc. ?04,1. tsunncs
<br />ud Fr.a6\ion Code: Thc Contmrors Li.cn\c Laq doc\ nor appry ft, a6o*n$ or prolcny rho builds or impn,!.\ rhcr.otr.
<br />,nd aho.onrn.lsrorsu.httrqdswnhrconrtucto(srlicerscdrurru$rrorhcC.ntncroi\t-ic..\ctjw)
<br />sl7,l
<br />Sc.lior .l]. & P.(t!
<br />I h.rclry rrfinnundcr pcMhy oll).rjuryonc oflhc follo*i.g dccli!.lions
<br />-l
<br />hlvclndwill maiohin uCcnilic rofcon\.nrbs.ltlnslr. fur *olk.$ corqEnsatiotr.0s pmvidcd forbysccrion:l7lx).frhc
<br />ti$or Codc. for lhc ncriornmtrcc oarhc work ior $hich rhc pcmir is i*!.d
<br />I havcind *ill minr.in w.rkcri.ompcns.thtr insurlncc. !s rcqnircd hySccrion:lTffrofrhc lihor cldc. aor thc Frlonmncc of
<br />ihc Bork ltr which rhis ,'crmil is hnEn. M y *o cn conrpcnsarion insuramc cuicr ii poli.y nun$.r d.
<br />PolicyNumbcr:-
<br />Icnilirh.rinrhcpcrtunuNcolihc*!rllorwhichrhGpcflniriststr.d.lshrllnorcnr.!.nyDc6oninlnym nlr
<br />$ a t) hcom subjcd x, rhc {o sr.onpcnrdn hus.rcnliromh. nftl!8rcerh0r itl should h$o.t srbj.rt b'hc
<br />$ork.tr conpchqrnnfr.visi(, s of S..rion 17(n.f rhc ktnr Cqlc, I sh0ll. ft,nh*irh complt e irh rhot ptuliJions
<br />civil hrc\ trp b onc hund.ctl llNusrnd dollars (11(x).1 l. ir addiri{n, k, rhc.o{ of.ornFnsrri' r. d.rrrgcs 6 nDviJc.l t,tr rh8
<br />"l)
<br />Orrt: i /2,b
<br />I bcEhy omflnunder pcnllryorp.rjury lhar I d liccnrd undcr pbvision ol Chr,,rq 9 (conmncins $irh Secrion 70m) orDivisi,rn 3
<br />of rhc Busift$ atu PmlcssiorN Codc- ord my liccnsc is in full l'ore ud .rfec'
<br />Li.cnsc Nuntxr:
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<br />CI,INjiIII]EITONIENDI!(jA{jINII
<br />I hcNb, nlllnnundcr IEMllyol pcrjury rhalhcrc is d con{rudion L]ndin! 4ci.y Lr th. |xr l'onutrcc ofrhc *ork l'or shich rhi\ n rntir ir
<br />tsDcd(se 3ID7, Civ. C )
<br />A.TTLICANLDICLAIAIION
<br />I trrhy aninn und.r p.nohy of pcrjury orc of lhc rblbqnrg dcchr0lions:
<br />Dcdolirion Pcrdns Astr{.\ Noriliftrbn F.dcirl RcSxldiuns (Tilc40. P.n6)
<br />R.qrkd trn.r.f Noria$r n
<br />I..niiyrhd lhc ltdcnlrcsulalions rc!4dins rdrnos rcm)lalarc noratfl'.$lc Io rhis !tu ccl
<br />-lccnifythorIhavsrcudrhisurulicarionudsraterhnrrhclhoreinf.mlionh.oncclIo8raloorrly*irnallCnytrndCounryodhon ci !.d Srrtc tjwc rcbuns la build'ns connru! xon. ad hcEty auho k Eprcs.nlaliv.s of lhis Cny sd Co!.ly l(, enld lFo t
<br />.*.Ih-,*-"
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<br />Apprk ,dAsn,sk,,m. Y '4rr'Z
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<br />D,,. '/lt
<br />/re
<br />Pemlre dm,prin,,: /tv*dL/t P-rzz-r
<br />Site-Work
<br />Underground
<br />Light Slandards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lite Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / 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 & Solfit Rouoh
<br />Ceilinqs (T-Bar Rouoh)
<br />Meter Release
<br />Rough gt lt?'T4.8)
<br />Service Meter
<br />FINAL tPl2lf ii Vlrru*,>b_)
<br />I UUNotes, Remarks, Etc
<br />Pole Bases
<br />WARNIN(;: Frilurc ro s.urc mrkcs' conpen\aliotr .orcmg. h unhsfnl. md sh.ll {rbr$r in cmplo)cr lo aiminrl tcnrlrir\ and
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