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ELECTRICAL-INSPECTOR RECORD
<br />DATE tD/stG.COMMENTS
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Faclory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soff it Rouoh
<br />Ceilinos (T-Bar Rouoh)
<br />Meter Release
<br />Rough
<br />Service IVleter I ILlzll)Z (
<br />Notes, Remarks, Etc I
<br />OWNT:R BUII,DER DEI,C,{R-{TION
<br />I hcrchy nrum n.dfi ,.nrliy of pcrjury rhil I an cxcmpr rrom rh. Conlhdm Li.ensc L.w lor lhc folk,sinE rcaen ls.c 70.11 5
<br />t usincss atu Profcssion Cqie) Any City.r Counly which equircs c rcmril l. o.ddcr, allcr. itwove. dcnslnh ot rclot any
<br />dtucrurc, pior to irs is!uan$. alqo rquncsrh. qrtlic{nr for ruch rErmirro fil.r siencd sl0tcmnr rhd h.or shc is liccnsed puNuanr
<br />ro rhc rrolisionr olrrE Contradois LiccnFcd LlB (Chlprcr 0. Connrcncins sirh S(rio. Tlxx) ot Di!i\nl.I dr rh. Busincss and
<br />PmicssionsCodc)orrhlr heorrhc hcicrllr rhccfromand rhc hqsis for rhc nllcg.d cxrmp(i.6. An, vid.l nolSeclion70ll.5byany
<br />applic,nr ror r pjnir subjc.B rh. appli.anr ro.civilpcnllryolnor moB dan fivc hundrcddolhB ($5001
<br />[-l ^ ., *, ,,r ,r," n ,r"ny. or ny erelo)rs c h *usc\ as rh.i' {'t .omr.nsriotr. will do 0f, work ed rhc srnr:rurc is nor
<br />'n'cnlL{ u,oficrcd fo, sk ls.r.7ul4. Busnc* und Pn,rc$ion. C.dd Th. Conrmcrors Liccnsc hs docs nol applr l. unort!of
<br />rhc pmrcny wlrr huids or inpmvcs tlENtr. and wls do.s ruch $lk himsclfor hcrclfor lhmugh hh or her own cq,lolt.s.
<br />pmlidcd ihar irch intmkrnh Rmr inrcndcd oro,lcrcd for $k ll howc& thc hnildiig or idlpmle ftm h $ld wirhin, 'nc tc
<br />ol co phrion, rhc Owncr Auiucr Nill hDvc rhc burdcn of nmvina ihlr hc or she dd nor l,uild or imptrN rhe ptuFny fu rhc pu,l.* of
<br />-1.
<br />as owmr olrh. pmp.ny, arcxclusi$lrconhdir8 Rnh licctr{d conrrlorlo onnrud rh. p.ord (Se.701.4, auems
<br />rftl lhli\si,n Codc: fic Conlracror's l-iccnse I-!* der nol at,ply r.otr o*ncr ofl}n)pcdy wh. builds or ihrmvcs thcrcon.
<br />rnd who c.nhck rur su.h pruj(ls wrlh a Conr.dorls) liccn*d puBu.r to Ihc Contracrois Laensc Law)
<br />I hcrcby !rltD undcr FcD.llyol'!.rjuryonc ofrhc lollowinB
<br />-lhrlcondrill'Minrain.Ccnificarcofcons
<br />ro Sclf-ltrrurc ld workcs conrtcnsalion, as pmlidcd fq b,sccrion l7c[] orrhc
<br />tjtxtr Cdlc. t)r rhc p.rfumn c orrhc work for which rhc Frnrir ii ilsucd
<br />-l hrvclnd w'llnmiDroir workers comr.nsarion insuroncc- 0s rcqut.d byScdion.lT0Oolrhc l,txnCodc. fo. $c l)crforrotre ol
<br />lhc rcrk lor whi.hthh Dcrmil is hsu.n. MysortcF omrcnslion insunmcfficr xlFlic,nombcr m:
<br />^
<br />PJ'hc] Nurnhcr
<br />-
<br />rrr.,c.
<br />flA 4o,", -,* ",.,run!.
<br />n,,hc tro,k Ln which,h^ F,ntr, ^ F\ud. r .hr, nn,' t"1L.N-* *rr.i or* trn,rq*,cnmrnsorien t!trl.rcahr,",n{. onJ JlmrhJr,r r
<br />cmploy any pcN)n in rny mflnicr
<br />\h,uld t{.on* {ubj..r ro ric
<br />*oltcn conrpcnslnrn r,relnionsofSecrn,i 37(xl ol lhc libor Codc.l shu ll, tonhwhh L$n1Ply wirh lhxc [.visions..
<br />::,+vir}lin#
<br />.onf.nsrrbi .ov.rrE. k unhstul, trnl \hrll $bjccl m cnltllorcr ro
<br />ollrs rslm.oilo). in Mdin rhc.o{ ol compcn\orioo, donra8c
<br />I hcr.hy tunu cr!..rlryoilcrjryrh.r I anr li.cnscdutrd.r Drovi oi Chxprq i) ( connRn.nrE wiihSNr6n 70tD) ol Dirhion l
<br />ol rh. Bu\nr\srnd Pmlcsnin(C.dc. nnd nrylr.d\c i\ ir nill nr.c rxicllt.r
<br />Licctrsc Cl.ss:-LilTnsc NumtEr:
<br />lr.re' ( onrrrclor
<br />C(TNSTRUCToN LENDINI; AGENCY
<br />Ihcrchy lflnflrundcr lrn0lryofFrjury rh lhc.cis!consrrucrion lending arcky ror rhc p.rfonMncc ofth.sork ror whth lhis Frmir is
<br />(sucd lsft.1097, Civ C.l
<br />APIIIIANIDEII.ABAIION
<br />I H'yafiimundcr pcnrhy otperj!ryorc oflhc loUowinr dccla6rnnN:
<br />Dcmlnion Pcrn rs-AstEsros Norification FedcBl Rcsular ions (Titlc 40- Pan6)
<br />-Rcqutcd
<br />Lcllcr oi Nolifrolbn
<br />trdify rhar thc fcdcralrcBul.riotrs EE&dinB 0sbcstos rcm!01are not lpplicahlc ro rhi\ noiccr
<br />rhd I hlve rcad rhi\ rppli.rrio. rrkl rsrc rhrr rhc !h,vc inf(r dion i\ cor(t. I ngrc tocomlly wirh rll
<br />.klinJn.r\xnllsl rr I-r!\ rchliru n) huildinS .tio.. $d hcrcbyaurhorn. r.lrc€nrarivcs oir 'tfirh)vc nBnti{nrcd proFny ljlr i'anccrbn
<br />ionl or AgcnlSiAMlur€
<br />I'enn @ nnD.(Dn ):\c
<br />hlL
<br />LIhYI
<br />APPROVALS
<br />FINAL
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