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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrcby !fiirm under nenohy of r,€iiory that I am cxcm from rhc C{ntr&lom Liens L.w fo. rhc rollosinp rcrsn {Scc.70ll.5
<br />ax\incss ! l Pmtession Cdc): Any Ciry or Coury *hich rcquircs r tsn r ro onsro.r, alrcl intlrovc. drfl,lish or rnan any
<br />struclurc. ,,rior ro ns ku c. rl$ rcqun$ rhc atrlkd for soch f.mi . filc r siSncd ndcftnr rhar hc or rhc t liccnscd aunumt
<br />ro lhc tn,v(n,os .frlE Conrmd\ Li..nscd Lla (Ch!!rcr 9, CommtuinE wiri Secrio, 7000.f Divhjo.I dt rhc Bnsin.s trnd
<br />Pmicssio.s Codc) or lhll hcorsic tcxcnpl lhcrcfrum rnd thc basn ror rhcalic8cdcxcmpliol. AnyviolllionoiScciion?0ll.5byany
<br />4tu;c** ffi#il;ffiffiffid;il:r;,ffi il.T",
<br />lhc pop.n, *ho blild! or idP,oe. rltNn- ad who docs $ct w* nimlclfo. hcrcllorltrol8hhn or hcr o*n enploy..a.
<br />oflrvidcd Ihor such inpmv.mnh c tut imcnl€d or.ftcri for sk llhokrirhct iHingor iqhv.tud i! q,ld silhin onc Fr
<br />of conplction, rh. OwEr Bu d& will havc rh. burrkn ol Imvi',B rhd h o' \hc did mr trild or i'npmvr Lhr I!6Fi, for rh pxri.s of
<br />-l-
<br />,s owrcr oi in. pmFdy. anr ctulusiv.ly conr,cring *irh li..n{d .oMa.roN k' con(Nd rtE Isjd (Sa 7O4J- Busncss
<br />rnd Pn,r.ssiD Co.lc: 'l hc Conrracrols Li.ensc Lrw docs nol atlly ro 0n owncr olrropcnywho builds or impDvcs lh€Eon,
<br />and who ontmcts tor such poj.ct eirh r ConrEdon, lic.ni.d puisu.nt r. th. Conkicrur'r Li.cns trw).
<br />Owmr:
<br />I hc,eby imln!nde, Fn0lryof p.rjuryonc.ilhc lollowir8 del.rar
<br />-l
<br />havc un will roinraifl ! Ccnificale of Consenl ro Scli.lnsurc Inr sorkqi ompctrsin,n. ss pmvi{i.d rbr l,y Serion :1700 or
<br />'hcliborCodc.l'orlhcpcrfon,onccollhe work for{hichrhc pcnni n Gsucd
<br />lhllcddwillrrinirinworkcriconrpcn\atn,nin\u!!trce.r\.cqut.dhtSccrion:17(l,ofrhcLtrborCod..fttrrhcFrfonnn.cof
<br />rh. work nrshi.hrht pcn ir is i\w.d My workcr' comp.n\llion irNurane.a cr mJ F,li.ynun '.r -.
<br />inrhcFcrfontunccofrhcqorkr(tr*hichrhi\p.rnir i\ '\\kd,I \hrll orcnlnoyrfyt rk irirtrynrtrn.r
<br />subjd lorhc wol(cr' onDc.slion laws of Cililoini.. aM a8rcc lh irl should bccom s!bj$' lorhc
<br />sorkcr' onlncnyrtion polisions of Sslion l70O ol lhc La&tr Co<lc- I shill. lon hwilh smnly wiln tho$ pnvhn,ns
<br />lVARNING lrailtrrc b {curc krkc6 c.n,I{n\rrnr corcrug. i\ utrlrslnl rnd \hll \ubr.cr rn. rtnor_cr r, cirnirralfndllic\ alld
<br />housrnd Jollrs (Sl00.0tD). ir iri{rn ro I r .f.omtcnsarion, dam8.s as [ovid.d fd thr
<br />Dare: A
<br />D!!Li-BdI]r2tt
<br />I hcrbyamirn undcr penolty of p€rjury thtrl l0m lcctrrt undcr Eovhion olChaplcr 9lmmmcncin8 wilh Sstion 7Ul0) orDivisioi:l
<br />of rh. alsiNss .nd Pmtcssions Codc. tud my li.cn* h ir tull for.. md cftc.r
<br />Liccnse Clas Licctrsc Nuarhcr
<br />tlte Contndor
<br />SOISIAIJT:UONIINIINGIIiENrI
<br />I hcEby rffirm undcr lEMhyofp€rjurylhar th€rc is ! onsrru.lion lcndins iscrcy {or lh€ pcrfororcc otthc *ork ror whi.h lhi Fmil iq
<br />issud {Se. 1097, Civ. C ).
<br />AITI,ICAILDECIAf,AIION
<br />I hsr{,y afim udcr Fnalty oa lcrjuly om of rhc ,oll*inB d€Lr.l ions:
<br />D.rcliliotr Pcrnrik-Asbcslos Nolific.lion Fcdcml Rcgnldrions (Tiilc,l0. Pad6)
<br />Rcquircd t icr or Noifro6n
<br />-l
<br />ccnifyrhat ihc icdcral rcBuhrions rcE dins rslEsosrcmovrlrc nor appliclblc ro rhir tmj.cr.
<br />uAAaIy rh,rr h,r *,,r rhtrsnnrf,ritraJ n arc rhrr rh. ah,rc iitir.Br ion is .on cr LErN ro mnlly wirh trll cir, nnd cotrory
<br />l+di'inn.s\ nnd srore lltr\ rclarmsrn hurlJrBronnrucnnn- ad h.rcb, lurhori2c rcpE\citrrilc*(,rrhisciryMdCounryrocnrc.u,nm t
<br />utrrc mtrlioNn pntcny fot irrsp.ctbtr
<br />'\pplirr l.r,lsrDl Sisnrturr
<br />Prmitemm(prin0:IN
<br />*,"t1s\ru
<br />Site-Work
<br />Underground
<br />Li ght Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Llje Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Condilioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />[alls (Rough)
<br />Ceilings (Hard & Soffit Bouoh
<br />Ceilings (T-Bar Rouoh)
<br />lVeter Release
<br />Rouoh
<br />\?-.<1
<br />FINAL )kt\r1
<br />Notes , Remarks, Etc.\.J
<br />DATE
<br />Pole Bases
<br />Under Slab / Floor
<br />Service lVleter
<br />-rI ?hP
<br />(
<br />lLr
<br />L.ndcr \ AdJr$
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