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ELECTRICAL-INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I heeby afiro ,ndcr pcnrlry of rcrjury rhll I d denllt ftum rk ConrucloN Lic..s. bw for lh. aolloein8 rc.$n iscc.701 l .5
<br />B!\indcs a,rl Profcsion Cdc): An, Ciry 6, cl,unry which ,cquircs n F,mir ro consd.r, ahc. inl,rclr. dcmlish or qEn !n,
<br />sr durc. prior ro ils ksu0ncc. .lso rcquncs rh. apllicrm ror \uch rrni' ro lilc o siSmd slll€Eol lial hc or shc is liccnrd pxuxu.r
<br />ro rhc rmvirio.s .frhe Cont,croas Liccnscd tls (Chaprer 9, Connnen.ine wirh Scclion ?0oo of Divhion 3 of rhe Busincs Bnd
<br />Prcfcssions Codc) or fiat tuorsne k cxcmpl thcrcfrom n.d thc bdsis for rhcallcscdcxemplion. Any!nn!rio.oaSccrion 70115 hym,
<br />amlicant for 0 pcrmir suhrccrs rhc lmlka.r roacivilp.nalryolflor mrcrhu lilc hu lrcdd.ll-s(1500).
<br />rfu,, rLl. !, owmr orrh. pml.n!..r m, cnrrrolRs qirh $lgcs as rhcn nh compcnssrion. willdo rtr Bork !d rh€ {mrm is mr
<br />/l# tA r"Htrcd ro, qhrs( 7044. Buqrc$and horcsions code: Thc conrrncroir t-iccn* tjs docs nor apply ro an owmi oi
<br />tfc pn.rdny etD bril( or urpoE( rhcdn. ui wh, .lfts $Eh wrk hin$lf o. hcrclf or lhFu8i his or hq o*n chtLfcs.
<br />provi'lcd lhal such impmvcmnrs re mr inle,@ or oficrci for eh l( ho*cti rht btiklin8 or nr96rcmnr is $rd uirhin orc )t!r
<br />or.omphlhn. lh. oRmr Buildc will turc ltr budcn of prcvinB tnd hc or shc dil n,l lDih or inorcle rhc loFny 16r rl'. pEl[s or
<br />-l-asowmrofrhcprcr.ny.!'ncrclusilelyconrrxcrinswirhliccn*dconraciocbconndd'riroj.d(sc.70t4.Bu;m*d t\ufN\iin Codc: Thc Conrn.ttr's Li.cnsc Lns docs nor ll)ply ro.n ow.d of!rulErry who buil& or imlrcv.r rhdr..n.
<br />snd $no conrracrs tor slch pojccr\ enh ! Co.rrocron, liccn{d pt(rair hrh.conrhcttr s Liccnsc Lrw).
<br />ion-. B. & P.q
<br />I hcrcby afiirnundcr ncMlry of pcrju.y orc olrhc lolloqin8 de
<br />IhavcnndwillnrinlrirrCcnnicdcolconsnlkrScll'ln\urclitrworkc.om!.trs0lio.,"spn)vid.dftnbyS..rim3?mofrhc
<br />Lrhtr CL{.. li,r rhc p.dormn.c ol rhc work for whi.h rhc ,.mir is issucd.
<br />-l
<br />hove rnd will mainlair qutc6 conrFnsslion iNurcmc. as rcquted bySccrk n.lTfi) ofrhc ljb.r Codc. ror rhc t'trfoirn!rcc oI
<br />rhc aork lor whichlhis!.rmit is nscd. Myworkcn ompcnsarion insuramc caricr ard F,licy nunrh.r ml
<br />4[,];;;.ilrr',ffi Hrn"#'Ir#rrr*,*'*ffi cmploy lny pcnoD in rny
<br />'natrnu\lk{ d hc.onf, \uhlr'.rt,rlk
<br />workc^ conrtcnstion ,n,vhions ofSccrion -t7([ofrh. Lltn Codc.l \hall- fonh*irh connly wirh rhos tmvisions
<br />WARNIN(: l-riurc h {rur. sorkc^ cotrp.n\rr( corc(gd i\ u lr$ful.shdll subiccl an cardoycr to qimi' l p.nahi.\ and
<br />:*..-{/1iiJ7
<br />lld rsl(x).(Xn). in addirion r .o{ of.oflrFnsarion. donE8cs a\ rmridcd nn rh.
<br />I hceby arfifln undcr p.nallyolpcrjurylhal I !m liccnsd undcr Imvision olChaprcr 9lconmn.ing wnh Scrio. T0Oo) o
<br />.f rh€ Bu\in ss and Pnnasqions Codc, nd my lic.n{ h i. tull for.c md cflsr
<br />CONIiIBU.(:IIAIi.LEIDINCAAINI;I
<br />IhcrbyalltmundcrD.nrhyoIpcrjuryrhnlthcrch!connructnnbndin!asd&yrorrh.FrrLnuncoltlEwo forwhichrhhpcnn n
<br />ii\u.d (Se :1097. Civ C ).
<br />A.8TLIIANIIECTABAIIO!
<br />I lrtr$y ll trM..lc rlr!oip.turyoncolrhc r.ll.wnrgd..h rnns
<br />Dcnrnirion Pcmrik A$csros Noriiicari,n Fedcral Rcsuhrion\ ('l irl.40. Prd6)
<br />-Rcquncd
<br />l.i'cr of Norifi carton
<br />. lcd,l,,hL rhcrdc'rlmEd'rrtr.n\r.Br,ti'ErLh.{ \rm,.vrlir. nor,'fflrxhlc h rhnfl, iccr
<br />4N,**, ,
<br />"*
<br />**
<br />^F
<br />anrlEd,ion and {r'c rhd ,hc sh^c 'nrn,tuii'1\ cnnn r t rF( h.n'
<br />onliMNes r Srarc rjws rchrirE ro hui[lnrts ru.ri,,n. rnd h.r.t,y3rrhori/c rcnr.\cir r'vcso{ thit
<br />$ovc rctrttnrd pm,rny for ins,'(tiotr
<br />ApDli.xrl or A*erl Si*mlun
<br />\
<br />:'*h]'r#'"
<br />Site-Work
<br />U nderground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Founlains
<br />Signs (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondino / Groundino / UFER
<br />Translormers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rough)
<br />Rough
<br />Service lt/eter rl ,--7t
<br />FINAL blTt\l( r
<br />'t-x'tK
<br />Notes, Remarks, Etc
<br />APPROVALS
<br />Meter Release
<br />1+
<br />L.ndq'i Addrc*'
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