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ELECTHICAL.INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER AUILDER DELCARATION
<br />I hcrchy sffi,rD undcr pcnrlrr 0l pcrjury rhar I !m cicnrpr lrom rhc Conrrucknr' l,i..nsc Lnw t, thc rdlowinS rc0bn (Scc 7031 5
<br />Bosin $ end Prorcsion C.dc): Any Cny or Counr, shich rcqxirc\ , ltmk 'o
<br />.o6(flct. rlr.., improvc. dcmlnh or Elat sny
<br />slflcturc, rior ro irs tsu,ncc. als rcqun s rhc rpdira for su.h tErn r lo lilc 0 siBrcd n cmnr thar h. or \hc is li.cnr.d pu^xdr.
<br />ro rne povnhns ol rlE Conrrktr\ l-iccnrd l& tcnqner 9. Conrncncins wirh sario. 7000 ol Division I of lhc B!\incs ud
<br />Phicssn,nr G)d.) or rhdr hj or 3h. is cxcnpr rhcr.fron ind rh. bask nr $c nllcScd cxcmplnrn. AnyviolalionofSc.rionT0:ll5nyany
<br />applicrnl lbr a permil subjcctslhc applicaor lo acivilpcnaltyofnor morclton 6vc hundrcd dorlrn ($5LD).
<br />I. ar owm! or rh. !nrl.ny. or my cmtlo$cs wnh wagcs a\ rhcn $h c.m!.nsdlion. Bill do tlE worl and rhc nntlm n nr
<br />inlcM.d or ofcnd ror elc (Sa.7(l1,l. Blsims a Pn,fesionsCodc: rhcCo mcroi s Liccnsc lju does nor lpply r. an owmr or
<br />rhc lDpcny Nto huilds or iqrelcs rhcd)n. tud *ho d{rcs slch m)r( him\elf or hcNc lr.r rhrouth hh .r hcr own cmploycc\.
<br />nrcvidcd rhat slch impmvc,Enls N nor inrod.i or oafsed for $lc lt ho*cm. lhc t{ilding or in{,mv.nEm h $h wnhin onc ,!u
<br />.f cor{,lclim. df, o*mr Buiks will hrw lh. budc. of pmvitr8 rh,l tE or shc dil mt l{ild or iryme h€ pDr8ly for 'rr
<br />pur'r)* or
<br />-1,
<br />osowncrofrnc propcny,0mcxclNivclycoirlcrinswirh lienscd conrncror ro conitocr rhr pmjdl (s.c 7L!1-,1. Bu\ims
<br />and aLts\ion Codc: Thc Cohi.ackn ! Liccnsc Liw do.s nor lprly kr an oun( ort'rupcnt *ho builds or nnfoves rhcrcon.
<br />,nd sho .on'tuB fd su.h tr,j.cr\ *irh r Coitr.k,(9 lntn{d Nisna h lh. Cont ois Lien$ L!!r
<br />Lcx.Dlpr undcr S(rion . B & PC lnrrhis rcr\tr
<br />D.tt: O*nerl
<br />WORKF.RSiCONIPEIASATI(N
<br />DE1;IAf,^IIAN
<br />I h.rcby rlfinnundcr p.ulryofp.!u!yonc ofrl[ f.lldwing dslanri s
<br />I huv. dd wr ll tuirnrir r ccd ilf,dc of Conscnr rr sclf.l.surc lar wor*crs- lomnensar ion. !s pmeid.d ior hy serion l?m of rft
<br />lltxtr C,xlc. for rhc p(rlormanc. of lh. w.rk for whi.h rhc p.rn kn\u.d.
<br />I hrvclnd will nrrnrdin workcra conr!.nsolion insunrncc.0s rcqutcdbyScclion:lT00olrhclihorC.dc,rorrh.pdronDnccot
<br />lhc work i(tr which lhh l).rnril is nsuL'd. My workcd compctrsrtnnr nrsur0ncc c(dcr urrd Flicy ounbc. c:
<br />Poli.t Ntrnrhcr
<br />--li\pir.\:
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<br />_l ccnilyrhar in rhe ll.rlor.Em. ofrhc sork fttr whichihis pcnir ir nsurd. I \hall nor .nlploy any ,n(r in M! mrtrn.r
<br />w, I t, lr.om \uhlccr b rhc *orkdJ .onD.nsdn,n hws ot Crlifohi.. rgN rhrl ii I shoukl hcronE subr..r ro rh.
<br />wo*c^' ompcn\arn,n !rt,visions of S&rn, 3700 of rhc Ijhr Adc. I shall, fonh*irh conrdy wilh ItDs ttr,visions
<br />IVARNING Frilurc r. scur! wortcm compcns iotr corcrasc is unlawtul. trnd shrtl suhj.cr an cmployer to diniMl pcmllis and
<br />ciril finc\ up h orc hundrcd rhou\ond dolhN l$1 ,.fi10)- in addirion ro rhc.o{ orconFn\rrn,n. drruScs rs uovidcd ior rne
<br />Scdi(nr lola.lrl[ l.rIitrC.J.. i, r'.{rrlrrtl
<br />,/lo f ,s
<br />I heel,y rfim undcr pcnllryofpcrjlr) (hd' ! m liccnyi !irl* !m!ni.norChap'o 9 (mmnrknr8 wilh Scclion 7OO0) olDivisi.n l
<br />or lhc Businc* and Profcsions Codc, mn my lic.Dsc is in full rorc aM clic.l
<br />Pt)c 2-z(o,#a14..""";.\
<br />coNiIBJJCuOXLtNtlIlti-{GENlr
<br />I h.6by lmrirnd.r Fn.lry of p.rjury rhar rhcrc k r.oNrudhn LndinB rgcfty fo, rhc pcrformncc of rh. work t r uhi.hrhis lBrmn is
<br />L(ndcr. AtldE$.
<br />-
<br />dIfLrcAlfD[CI,I.BAIIOtr
<br />I ltn$y,fim un'lcr p.nalry olr{rjury onc ofrh. ri,lbwir8 dc.lrilions
<br />Dcnx,lirio, P.rmih Asb.d.r N.rificnrion Fcdcrol Rcguhiions (lirlc4Il. PM6)
<br />-llcqutod
<br />l,rlcr ol Norilicxri) r
<br />lcrdiiyrhd rhr fc{lcralr+ul ii)d\ r.BirdinS r\lrno\on.r l '. norlPtli.ihlc h rhnfrl$r
<br />l.dify rlu I hrv. icld rhis rrtlicntiotr and nrrc rhd Ihc atx'rc itrlormtiotr n corccr lrEreio.omllrwirhallCiryaDdCounry
<br />ordin.mes, ds'aretiwsrchrimlobuildinEcon(rucriorondhcrcnyonrhoriTcrcrrcscnrarirc!olrhtCiryrdc.unlyiocntntrpo rhc
<br />".,. s/ro f ttff:,:::ffi:'."
<br />P€milm norE I prinl):<fr*oo
<br />Site-Work
<br />Underground
<br />Pole Bases
<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 />Bondin g/Grounding/UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduil)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Bouoh)
<br />lt/eter Release
<br />A
<br />Rough ,-214y Y-WL
<br />Service lt/eter }}
<br />FINAL t:-b"tv
<br />Notes Remarks EtC.
<br />APPROVALS
<br />x"u-0[)
<br />L*
<br />tsu€d (Sec. 3097. Ci!.C.).
<br />Lcndcir N{mc:
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