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ELECTRICAL.INSPECTOR RECOHD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrcby !fiirm undcr Fnah, of pcrjury rhar I am cxcmfl frcm thc ContadoF Liccnsc ljw for rh. fdk,win8 ,c!{,d ($c 70.11 5
<br />Bu\iness nl Profcssion Gdc): Aiy Cir, or Counry which rqute\ a le.mir lo co.(dcr. trlrs. id\rovc. d.mlilh Dr d!,t any
<br />{ru.rur.. tmr ro ir! ilsuancc. dl$ r.quner rhc amlkanr fo, ruch lcmn lo fih a \igmd {rtcftor thr tr or sh. i\ li.cnsd puKuanr
<br />ro rhc provhions olltE Conlrrclois Liccnscd Lap (Ch.rlcr 9. Commncnr8 with Scclion 70Ol).f Divhion:l ofrhc Bo*inc* lnd
<br />Pmttssbns Codc ) or rhd ltorrhc h.rcmtr rhd.from and rhc l,n\is fdr rhc alhBcd .k(prion. AnyvioldionofS.crion?0:ll5byrny
<br />/Fndn,fl rcr a nc n \uhj(crhc.ml.crnrrotrcrrllcnJk)nln.'nmmrhrnlnchundreddollus'S!D,.
<br />fi\llJ,**.,,*,-*"y.u,n)rn{,rnrc\qi,h*asesas,hcns.comp€ns,n,n.* d,,,tEwo.kux,,h.{turmn*,,
<br />/'{.rifu * "r""!t r," *t rsc 7(t -1, Buvft* rnJ P6fe*tun\ Codc Thc Conoa.rofs Li..n\c tj* (n).i..r alply ro an osE of
<br />rh.fmFfly qh, huilds or iryrorcs rh.ren. md rh. nas sch e* hinscll or hcr$ l{ or rtnuen nh or hcr o*n cmrk,yces.
<br />prolidd lilt \uch imrmEmnls m mt inrqrlcd oror.crd for slc.ll h.sctr. rhc tdildin8 o. iinovcmnr iseldvirlinorc }Ir
<br />ofompLlion. th owmr suii:hr will ho€ tE huni.. ofrruvinS rhr hc.r shr dil id t iU or in{,mw lhc In,lcny aor llE ru,Inr of
<br />-1.
<br />as owncr ol rhe prupcny, { r cxclusircly conracring wirh li{ned coMador ro on(rud rlE Imjct (Sc 7ol.t, Buiinc\\
<br />anl Pofcssin C6dc: Thc Contr.ktr s Lic.is. tjw docs mr aptly k, an owncr ofpr.pcnt wh. huildr or impmvcs rfurcon.
<br />and who €onrrlcts for suci projccls with a Contncrons) li.cnsd pursunr ro Ihe Conlra.rois l,tcnrc ljs).
<br />I hUdhy rlli'mutricr t,crr !y.r |.,itrrvonc.r rl'. k'll(NiDr
<br />-l
<br />hrlc ondsill mrinr0in 0CcnificarcofConscnr ro Sclf-lnsurclor qor[eN compensation. os pmvidcd for byscc'i.i.]7(n.frhc
<br />hhorCodc, torrhc pclorm!trccof lhc workl'or wnich rhctcnnil i isstrcd.
<br />_l h t ,nd sill nrinuh s.r[c6 co'nrcnsur ion nFurorcc. 0s rcquted b, Ssr ion :]7no oi rhc ubor CoJ.. in
<br />'hc
<br />p.rronnn.c ol
<br />lhc work lor which lhis!.nnil is hsucd. Myworkcri <rpcnstion nrurunccc icr ud F,lty nonrhcr uc
<br />PolicvNumtcr: L:xpne
<br />/Mfu,,,",,..-",,*"".,,,. h,h^nf,mrF,..u.r,\h.,,nu,v L,f^ ro *ou*.ut'6cr r" rrc "orta. smFn{rDn lJtr, ol t rlrtnmr.'. .rd rtEc rhd rfl
<br />.ntloy dny Fmn in ony.nanrct
<br />shou[ lEcnnE suhj€cr ro rlt
<br />wolkcls ..n{..\altun !fuvisn,trs of Sccl ion l7m ol rhc btrr C'dlc. I shrll. fonhsith d,mply * irn lhor peyninn!
<br />WARNINC: r2ilurc ro surc workcis'
<br />*::'Urytr
<br />con cnsnnr mtsagc t utrhwful, 0nd shall subFl an cmnLrcr ro simhA,/\,
<br />r rtrrsrrr uhr rrY.rtion
<br />Dr!r l1rA rx,\
<br />I hcrby anrDlndcr pcmlryorFrjoiy ihar I an liccn{d lodcr p(,!nion ofChrfld 9 t.onfticing wirh s.crion 7fix)) olDivisi{,r 1
<br />ol rhc Busincs lnd Pft,fcsn'ns Codc- ! nry li.cn{c h in full |ore and cilccl
<br />l-icc \.Cl s: l-iccrsc Nr rhlr:
<br />Dalel
<br />CANflf,.IJEIIONIINDINJJ.AGINII
<br />I hcruhy rffirm und$ lcNlty. f l. uryrhd lhcfu isa.orntucrirrn lcndingrgch.y lorlhc|. onnlncc oflhc $ori lnrrhirh rhi\ rf,m,ir i\
<br />i$ucd (Scc :109?. Civ C )
<br />+tn;;;
<br />fcdcrJlrc8oLrnnr ftSddi'rE r\h((o\ r.nxralrrc nor llplicrblc r, rhis |n,jccr
<br />rrd rhis dmli.rti.n rftl sd. rhar rhc rh.v. i.f(mrarmtr iscon(r.l agr ro co Dply *rh lllCiry rnJ (innn!
<br />Ci'ylndCounrtr, cnrcr tr n rh.*s r.lrl,n8 b huiltlinA con cr io.. ,kl hcrcby lurhornc rclIc{ntalircs
<br />ultnc nrnii{,n.J pn)p.ny nn i'r9r.ri(nr
<br />Appliunl or Agetrt Siln{n'r(
<br />P(mit( mmc lp.inl):6 "...,1r]qk
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dam pers
<br />Communicalions Cable
<br />Building
<br />Bondinq i 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 (Rough)
<br />Ceilings (Hard & Soflit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />Meter Release
<br />Rou gh I
<br />Service Meter ll t (/
<br />FINAL u ntln A
<br />Notes, Remarks Etc.
<br />Under Slab / Floor
<br />(,t{
<br />AIPIICANLDECIJAA.ITAN
<br />I no.6y !frm lndcr penalry oa pcrjury oic oflht followin8 d(ltrarion\:
<br />t)cmolilion PrnrnsAstrslos Notilicltion rtdcrul Rc8ulal ions (Titlc .10. Pon6)
<br />-R.!uiFd
<br />Lcrt.r of No{ificariotr
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