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ELECTRICAL-INSPECTOR HECORD
<br />APPROVALS DATE tD/s[.;I COMMENTS OWNER BUII,DER DE!-CARATIoN
<br />I h.r.6y alinnr nnlcr prmhy,n pcrjrrr rhrr I m rtrmrr rioD th. CDtrtrr(n,F Lrcn\c t]w l,rlhc tull('*ng [rn,i fsc.7(,.r15
<br />Bu{nc\l r Pnrc\\i,,n C,rlc) Atry Cny r Crtriry wl,i(h r t, .onsn.r. rlrcr, inDn!.. &nx,lAh Dr rqvrn oy
<br />(rLt. lnn.n' [\ rsurD.c. rlv) rcqut.! rhc rpt]lonr l(t {(h ltnn ti lil. r lgncJ n cntnr rhar tr.r \hc is h.cn{J ptnutr ,
<br />k, rh. pn'!trr,n\ ol rh. Ci a.ntr\ L(.nsc.l Lrw (Clrpl.r 9. (,nnfrrrcln3 $i(h S.rr(r 7lX[ rfDrv,\.n I dl rh.Ittrlin's rn(l
<br />Pftfts\ nnr (i)d. ) .r IhrrtE.r.hc is c\cmpr rhcrclroninJrM h!ri\ lrn rh. rlL!.d crc rrrnnt nyvrnrrrrolSc.rhn7l).\15hyxtry
<br />lpph.inl li'r r pcrnrir $hj(( rhc rpfhrnrt' a0v'lp.nrlrtol'nn nrhin lrv. hunJir'd dollis ($5(x)r
<br />l. .\ owar ot ilr pn,Jrny. n my cmflo$$ wilh waecs ,r rhctr ('lc .omp. er nn. w'll Jo rh. work iJil rlf, {tuh'rc r rtn
<br />i'ncnlci or olicrcJ li)r s,lc (ScL ?(tl4, Brsmcs rnJ Polisi,,ns C(il. Tl* ContMttr s l-i..n\c l-iwnocs nor rnply (, an o*ftr ot
<br />rh. rn)l*ny who h,ildsor n\xovcs rh!R)n. rfti *h',nrs \'.h *o* hinscllor h.rdlor rhn{sh hr\ d lrr.wn cnfl')y.cs.
<br />I[,lricdrhd {rh nnln.vnxnr\ ircn,0 .nlcd u trllcnal I'n slc.lr. rx)xcv.r.rtu htrilliry r inrlr.rcnrhr '\
<br />(,U r-dhtrr.nc lcr
<br />ol .on{,Lr on. rhc ( }wncr Br'LLr w'll h,h rh. hrrd.tr o, t)n,vng rturh(orltf,'Jrl n tntrltl or inDorc (lE 0n,Iiiy la. rtr nurir,t ul
<br />__l l\ ownd ol 11[ Ill,tr.nv. r ,.\rhtrnrl! ! otur.r ! wih |,..r\'tl c.trirr(nnsn,.on!n'd r,F pn,r.cr lSc. rr|t1 Bu\n.\!
<br />itrd who (onrBdsntr\0(htn,t.6 sirh rCrnkr.tnl\) I'Nh\cd ptrr{( t,rh.(ntrnr(h \I'..n\cl.rw)
<br />I rn.\.n,fl trnrld S.!rntr,
<br />!!!lB6!B[!l]!!!ENldla!
<br />!!Eet B n9!
<br />I hcrchy rltumund.r r^-trrlry ol pcrjur y onc oirhc n,lhwmg J..hriri,,r:
<br />I hr{ rxlwrll nrot. rCenrlicai.ol(inrcnrn)S.lllNurel,nworkcr'.oml)cn\dhnn..( Iln)v.dt}rbyScdi,n.171X}olrhc
<br />I;'htr(ixlc,turrh.Frt.rmdn(.ofrhcworkl(nwhthrhctrfln( rlsu.n
<br />Il \.rmlwrllDrr rn *orkcrr .onr.nsrrtr n{nrnee, rs r.qtrt!lhyS (ol7lx)dlrhclrhdr(i)(lc.,nrihcP.'li)rnuf.ol
<br />whkh rhr t(.!ir t isn'dJ. Mvwo,k.'r (o'nn trsrriotr iAtriur.!rnkJ rllr'l'.yrunrlNuc
<br />INn[_vrh rh(Nrn)rnutu.olrh.sorklarwhLhrhl\It', tr Anh,.I dr]ltr.r.{rnl,,yiny t^-.non 'nrnyn,rnn.'n, r\ h lf,(nrf, \uhj.rr b rlf, wn kcF . nlJ'.tr{rl i)n lirs .l (-rlrlnr nr. rnJ q'r. rhrr 'l I nr]u lJ li( nk {rl'r..( nr r lf,
<br />work.r.of.n\rrxn,ln,!AtrJn(.tS(totr1r(X).lihcl-ilrn(iin.lshrll.l,nlhwnh.rnl!l!sirhrh){t'x)vrntrr
<br />W,\RNIN(;: lril,m n) \.rur. *orkr'\ (otr,p!t\roon $vc'rlr ,\ t [*t1. arl \hll {ihr.'.r , .mpl,,)u k'.nntNl rmlr.( rn!
<br />htr t,rl. ' .'.! xn.lx(,nNr'\ 1\'r.
<br />DECIAEAIIg!
<br />I hcrhy a(irm un,lcr lcnrlry.Ipcrjry rhrr I rh lidn<d und$ F,vnx)nol Chipr.r c (onrmncin3 wirh S..rr)n 7000) ol DivrNn !
<br />.l rhc Aus,r$ intl Pdi$i,,nsCdle. anJ ny licc!* ii in ttlln,( rl.l1id.
<br />_L,(n{ Numh.r
<br />IONiIBU(]IONIENIIINIi.dIIIICI
<br />IhcE$y rllt unJcr o.nrlry ol l.rjurr rhd rhd. H r con{rcrDn ltndop rlcn.y lnr rhc pcrtrm]tc ol rhc work li)r *hiuh (hi\ r^-r mir ir
<br />r(sucd rs.L. 1097. crv. c.)
<br />APPLICANT DECLARATION
<br />I hcrehy dnim un,lcr pcnahy otrriutyonc ot ihc totuwinS dc(lnr.lions:
<br />D.frr(i,nPcrmillAstE(os Noriliutt'nF.dcral RcBular(,n\(Trlc40.Pd6)
<br />Rcqurcd Ldrcrol NdilMri{nr
<br />_l (cn,ly rhrr ifu Ldcrd rclrhri'n( ,tg{J rI rlti{.! r.nr)vrlrc no( rnpliuhlc n) rh,s Frt(r
<br />rlir( nxr rnrJ linit{ny l!
<br />ADIli.snt or ,\tctrl SiAnrlu
<br />! n(n,rrk)n. drl lr'.hyrurlktrr. r.JrcQndrc\.1 ',:,,:,","r'u^;i/-'-
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Bondinq / Groundino / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Boof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)/r-...\
<br />Walls (Rough)2-L141 x JltLlL\l
<br />Ceilinos (Hard & Soflil Rouqh F-F ,
<br />.VJq'A
<br />Ceilings (T-Bar Rough)\wa)
<br />lvleter Release l-/
<br />Rough
<br />Service lvleter r\\
<br />FINAL t6-x-1 )\ulri
<br />Notes Remarks Etc
<br />Under Slab / Floor
<br />I
<br />LnJcit AJJrcs
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