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ELECTRICAL.INSPECTOR RECORD
<br />APPHOVALS DATE ID/SIG.COMMENTS OWNER AUILDER DELCARATION
<br />I ierchy aiIfln undc, n nalry oi ncritrry rhar I o cxcnfl rbm rhc conhncroN Lk n* hw ror rhc iollowi.E rclsn (S..7(r.ll.5
<br />Brsind* aJ Porcsion Cli.): Any Cil, or counly whi.h ruqur.s r Fnnil ro conslNcl. lltcr, nnrruvc. dcdrhh or Nr€n iny
<br />rucrurc. prior h irs nsumc..lso rcquircs th. ot,pliant ior suchFnnir b fiLa isned ddcmn! rhdr h.or shc is lic.ns.d ,u*uanl
<br />ro rhc F,vhions of rhc Conka.t, r Li.c6*d tiw (Chaplcr 9. Conrmncin8 wirh Scclion 7fl10 of Division I .f rhc Busincs and
<br />Pn,L$iotrs Codc) or rh,r rE or sh. is crenDt rh.rcfmfl and lnc hasn lor rh. allcsed crcnPri.n ny vn dlionorsc.rkn 7011.5 by.ny
<br />rr,llic.trr ior a !.mir subjals rhc eplicanr ro a cilil penBlry ol nor me rhr. nvc hundrcd dollrs ($50)
<br />-1.
<br />a\ o,ncr ol rh. prpcny, or my eoploJr6 wnh w,ec1 0s rhct solc o'rycnsarion- will do fie $ork ar thc smlmI ml
<br />inl. ldl oi oflaEd ao. {L (se.7(},.1. Businc$ and Prefcs\n,ns Codc l hc Co.t!.ror's Liccnsc ljs docs oor spdy h h o*mr or
<br />rhc pmFny *ho Inildsor ilrllmRsrtEN.. and who des such *o hnhs.lt or h.t$lf or rhnugh hi\ or hcr oM .mlloyccs,
<br />nnvidcd thor such iq,mrmnc m nor int nd.d d orcd r(n $lc. ll howcE. lhc huitliiB or iqtrov.@n' is $E wnhin .nc Far
<br />ofonplcrion, tu Owtre Buillcr wiu haE th€ bur&n ol'povin-q lh.l lE or \hr dil d buitt or imro{ rhc pop.ny for lhc l)Urlnt oI
<br />l. $owncrorrhc pn,r.ny. a'ncrclusivcly.onroclirawilh liccnsdco rdoEt &n{d.r ttE PmFct (Sa ?(44- Bu\im\\
<br />atrd Pmn$ion Codc: Thc Conlrrcln\ Licensc Lrw dms ior aprl) lo dnowNr ol prorcny stx,l,uildr or ifrpii,vcs rhctcon,
<br />ond {ho conrrach lor skh !bi.t\ wirh n co.tE.ro(s) lic..scd rusu!tr1lo thc Conrract"} l,8nsc Law).
<br />-lrnrercnrpr
<br />undcr smr
<br />Ormr
<br />]Yl)axlBllj!)lltlxsa:IlaN
<br />DIiCITSAIIAN
<br />I hcrcby rrind uidcr,rn lryol tEiuryorc olrhc iollowir8 dc.lararbn\
<br />-I
<br />halc drd will rtuntrair . Ccdiamrc or Conscnl lo Sclllnsurc ftn sorkdi .on{rnsdion. as tmvidcd for by S.trii,.l70onrrh.
<br />L{bor Codc. ,o, rhc Ilcf.inrmc or rh. w.fk rir whth rh. ,crmil k tsu€d.
<br />I havc and wrllrn.intli. workcrs' conpcnsalion insuEncc- !s rcqutcd hyS(rnrnl?00 oflhc Libor C,)de. fitr rhc lcdomuRc of
<br />lhc w.rk iorwhichtht pcrnril is isscal. MyNorkcri compc.sdion insur.n.. cric. and Irlty numhcr el
<br />6y'8-,npT
<br />PulicyNumb.r: ' Erpitc
<br />I ccnilr lhor in lhc perlorm,ncc ofrhc sork for which rhis linnit is tsuctl. I shrll trol cn]ploy rny lc6oD in rtry nrnlcr
<br />$ !s ro hccoru srhr.cr k, rhc workcrJ c m,E snrionhwsofcnlirornir!trdrgrccrh rll should h.conE sul,jccr brhc
<br />sork.^ c.mpcnsarion ptuvi\n,trsol sNlon 3700oithc tlbor Codc.lshlll, r(fhwirh (onlnly wirh lhxc Pmvtion\
<br />WARNING Foiturc lo sulc {orken' compeosarion ovcEac i\ onlawrul. n J shrll suhJc(r an cnrL,rlr k ciminrl ,fniltts and
<br />.ivll lincs un ro .rc hundrcd rhousand dolhn i$loo,Om), i'r dnii,n kr I (xt or &nqinerion. danses as Povid.d for rhc
<br />Scdhn 3016.irhclnh,(nd..n .rcnr.da(kr Ly sli.\
<br />"",.,'o//g/24/{ noo,,*,,
<br />DECI.ASA:IIQN
<br />I h.rcbr,filrf, u.dr pctraltyofpc+ry thlt I am liensd uds pmvtio. orch,,)lcrq (conrmming $irh Sdrion 7000) ofDivnion 3
<br />oI thc Busincss and h.fc$io.! Cod.. and my li.cns is in tull forc 0nd cffst
<br />/o -/" 7 t)c 2
<br />'6/lY/ 2,, t c"ntr"r*,Xr
<br />CONSIIIJCIII.}XI.DNDINC.&GENCI
<br />I h.6by rfltn undcr lEn0hyolp€rjurylhal rhcrc h tr on{dcri(,d lcnding aSrncy ibr lhc Pcrfom'tc otrhc wo.k fnr which rhh P.mi n
<br />isucd (Scc 1097. Civ. C.)
<br />ASILICANLDECUAAIIO!
<br />I Mry afiim uod$ pcMhyof Frjury onc olthe followins dcclaErions:
<br />Dcmlirio. Prrnnr-Ash.sos Nolilicdion lcdchl Rcaularions (Tillc 40, P,n6)
<br />-Rcqutcd
<br />kncr oi Ndifu di.tr
<br />k6i;ll
<br />Ihc ndcml rcsullrions rcsardins arh.dos rcnt,hlrtu mrnpplic$L h lhis pmjccr
<br />lhn\crcid rhnrmlicr.on and $rcrh lhc ir cor.d.I dgrN r) comply wirh !llCirytrnrl Coutrr,
<br />arc I aw\ rcl ring h buildirgc.n{fl.ri(n ,.r,,.\.irrnr\ oilr \ ( irr rnn (-r)utrr) rtr. ru txnrrlr.
<br />ibovc rm'll nrrd prcpcny for inspccri,,n fniF$r
<br />Appli@t or Agmr Sienctur: X
<br />e"^t**^,,c,,.o,f,= 44 J 141]rla/t4 /
<br />lr/ trla'il
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Liqht Slandards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communicatrons Cable
<br />Buildino
<br />Under Slab / Floor
<br />Bondino / Groundino / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilinqs (Hard & Sollit Rouoh
<br />Ceilinqs (T-Bar Rouqh)
<br />Itlleter Release
<br />Rough
<br />Service l\,4eter
<br />FINAL h/4)llt )l)ls)
<br />Notes, Remarks, Etc
<br />fT
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