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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS ID/SIG.COMMENTS
<br />Site-Work
<br />Unde rground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safely /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Vllfls (Roush)
<br />Ceilings (Hard & Solfit Rouoh
<br />Ceilings (T-Bar Bouoh)
<br />lt/leter Release
<br />Rough 4ls /tq :rl 6(
<br />Service N4eter
<br />FINAL lo/q/ n ')>Kt
<br />Notes Remarks, Etc.
<br />r)11\t,tR Bt .tr..t{ I) .(,\knIt(r\
<br />I hcrchy allirD u.dr F.ih, ol Frjury lh,l I m crcmrr lmn rhe contrr.^ Li&n{ I*w r.r rh. roll.wing rc$on (Scc.7ol l J
<br />Businc$ ml ltolcssn,n Code): Any City or Counry which rcquncs i lEnn ro conslrucl. ohcr. nntrovu. dcooliih o. (pair m,
<br />$rucrurc. lritr k' ir\ irsuatuc, alro rcqxiEr rhc{pplicanr ar suchFrmir ro fikd sigtud n0!cn.nr lhd h. or rhc ir li.cnscd rutsuMt
<br />to thc tmvGions oli,x Co.k.crols Liccnsd L.* (Chlprc.9. C.nrftftiig rirh Scclion Tuxr of Divnion -l oI thc Ausincs and
<br />Pntcsions Codc) or thnl hc o.shc hcrc rl)llhcrcliomandrhcbtrsisntrrhcrllcscdcrcmprioo AnyviolarionofS(lhn70.ll5hy!n,
<br />applicanr li,r ! pemir subjc|s rnc applicanl lo a civil p.nrll y oI ml mrc rhrn fivc hlnnrcd doll6 (3500,
<br />-,.
<br />0s owE of rhc pmpcdy, rn my cmplolecs wirh qd8cs a\ th.n \)b .o rtxi\rr ion. will do rh. $ork ut thc slnEtur is ml
<br />i cftld or off.rcd for sDle ( Se ?0t4. Busincs md hofcslionr Cdc 'fhc Conr.rtr\ l-iccn* I/s doc\ nor ,prly h an .wmr of
<br />rhcpmpeny who huilds o. i ill'ros rhcNn. ad who dBsRhw* hnns.lfor hcrelfor rlrouSl hk or hn own cflrployccs.
<br />ptoridcd rtar such inD,o{mnls m ml inrcR cn oroffcrcn for *'lc.Il ho*ocr.lh. hrillin8 or itrl0mvcnrnt h sUwirhin"rc Fr
<br />ol conrtlclion. lhc Ou ncr Buitls qill llrvc rhc iddcn of ln)vi.8 he or shc dil tur hxild or nnpn,vc rhc ,DFny ft, rhc ,nrF{ or
<br />I. ,\ owdcr ol thc l),o[)cny. !'ncr.hsiv.lyconiEcting *nh li.cnscd conrracrr\ ki condflcr rir Ir{Ud (S.c 7(l1J. Bu\i"c\!
<br />and Pmlt$hD Codc Th.Cotrt.crofs Liccnsc l-.wdo.s nor rtplyt' an owmr of prolEny qho burldsor inrprovcs rhcrcotr.
<br />atrd who conrr&( ror such pmj.ck wnh r ConrEcrorls) liccnscd luBuanr rorhc Conhcroi\ l-iccn\.li*)
<br />lrtrrcrc rtn uido Scrri{)d .B &PC f,nrhi\r. {,r
<br />Dal€: ()qn€r
<br />rvonx rn-s' r r w pruslrrriu
<br />0[cl.]I[IUqN
<br />I hcrchy nl'innrundcr Nn.htol Fturyonc ollhc folh*nrt dccltrrli.ns:
<br />-lhavcturdqillmi
<br />rm ! Ccniff,arc o, Cone lo Sclrlnsurc rM workdc conrpcnerion,0s pmvidcdforhrScctn'n.17(xroathc
<br />Lrtitr Codc, f.r rhc Frforroncc ofrh€ sdrt f.,shich rh! Dc.nrir ! hsucd
<br />_lhtrvcrndwillnminr,inwork..ompcnsariotrinsuran.c,astuqunrdhyS.ctin:r7(x)ofrhctahor(ndc,fo!rhcpcrf{,nMrcc01
<br />rhc \o* for whi.hthis pctmit is hsLcd MywortcB co'qcnsarion insumrccc!trhraM plic, truorhq arc
<br />nr.l ,,,sc.,+ Co5h.. t ur.Wtot t.\.t{.
<br />I cenily rhal in rhc pcrlorrotrcc orrh. sork ior *hth rhh |Ennit h isslcd. I rhlu nor cmploy rny Frsn ii rny roikr
<br />h 6 ro b.em subj.rr tu fic *orkcs .onqr trrion hw\ orc,lirdiin. rJ.,!rc rhd irI shorld bccom subict io thc
<br />$o.kcn compcnsrion povhiotrsofScrion 37u) orrhc tjtDr C.d..I shrll. fodhwirh omply with thos,mvtions
<br />WARNIN(;T Frilurc b *ur. workfiJ
<br />civil itrcs up tu .nc hundrcd lhousnnd
<br />Sc.rhn 1lr'76.frh.laktr ('onc i' .rc{
<br />.onqrisnrid, co!crr!. is unh,rll md srrtrll subj..r xn cnlPk,ycr t, crirnimlrMiic\ a
<br />dollds (Slm,off)), in dii{,n r. rho.oi of.ompcnsarion. drnrBcs os pror cdlbrrh.
<br />4,.C.t+
<br />I hcEtyaliirm undcr,,cnall] olFrjury rhar l0m li.cnsl utrdcr pmvision o{Chaprg 9lcommNins qiri Ssri,i 7O0O) orDivision 1
<br />of lhc Busincsand Pmfcssions Codc. and nryliccnsc ir ir tull nn.c 0fl1cficcl
<br />{=IoarQ t 1
<br />,rrr", 4a?.rb.(al<2re.
<br />CONSIBUqUOIi.LENDING.&OENCT
<br />I hcrchy.l6rnundcr Fn,hrorp.rjury thal ihm is a snitudion knding,gcmy for lhc pcrlonMrcc olthc woik for !fiich lhis pcnnir h
<br />hsucd (se 1097, cie. c.)
<br />dXILLCANT.AES,TB.TIION
<br />I tErt, nrrm und.r pcnrh y of pcrFry onc ollhc aolk wing d..lnrarions:
<br />D.frnnbo Pcrds Ashcdos Noriti.ari.n F.d.ral Rcsll'rions (Tirlc40, Pd6)
<br />-Rcquncd
<br />kn( ol NorilEnrt,n
<br />_l.cniryrnar rh. ltdc8l rcsularioN rcB{dins Lsbcno\ rc'novalarc lor q,plicablc ro rhii lnjccr
<br />tAldd-niry rhd I hN. rca,l rhis edi.rrion and ('rc rhar rh. atx,vc irfoamrion is conccr I .Bre ro omply wirh all ciry lnd counry
<br />oftlimnccsdnd Sr c tiqsrchritr! b iu itunrB con{o.t io . dd ivcs olthn Cny anl Counly b ctrrcr trFnrrtr
<br />ftok mcrin cd fbFnt rd insF.'tr r
<br />Applicrnl or AAenl Si,lrrlorc
<br />a'a !.L't4,
<br />DATE
<br />L n,lc, \ ,\J,1....
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