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ELECTRICAL.INSPECTOH RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I h.r.hy lmiin undcr lcnalry ol Frjury lhrt I !m qcrpr fmm lhc Conr,cloF Lic.ns Law ior rhc followi.s r.a{o (S< 7031 5
<br />Busincs arn Prol*sion Codc): An, City or Coury which rcquircs a ,'cnir to mn(tucr, ilrcl inprolt, dcrclish .r mNr d)
<br />strcrurc,,.ior ro irs tsuancc. lkorqrircsrhc aDDlicd for such lElnir ro lile r \iErdsr,rcmfl rha( h..r shc is liccnsd pusu r
<br />k, rhc prcvisnb ofrhc Cont,.ro L,.cnsd Liw (chaprr 9, Co'nmcn.ing wirh S€clion ?ulo oi Divhion I ofrhc aurincs,nd
<br />Prctss nrCod.)orrhll tEorshc is.rcn{rl thcrcfrcmand th. basis lor rhc dllcscd cic'npriri Anylnr{ionofs.diotr?031.5by!try
<br />applicanr tu a pcrnrir slbjars rhc zppltuanr ro,.ivil penuht.{not mor. rhai fiv. hutrdrd dollds ($50o).
<br />-l.
<br />ss owncrofrhc pmncny. {r myemplo)es qili qaScs os rhct slc comp.nslrn n, *ill d{, rhc uork,nd rtE slMW h mr
<br />inredsl or oifcred for ele (S( 71X4. Bxsines and ftof.\sion\ Codc Th. Commcrol s Liccnsc kw docs not anDly ro atr oencr of
<br />rhcln,Fdy who toilds.r nrpm6ltrmn. rnd *ho des su.h md( hinselfor hc$cltor Ihml8h hh o, hc, ow.cmplotms.
<br />pmvidcrl rlur such iflrDnlcnEnt\ m mr inrcdct orolleEd f.r sh ll l&woc. rhc irildin8 or iq,mkmd n $h wilhin onc }te
<br />of coq,hrinr IrE owncr 8uild6 will hlvc rnc hurd.n of lmviry rhal hc or shc dA nn bnilll or iryrow rh. pmFny rot rlr pu{F* .r
<br />-l,
<br />u!o$nc.olihc prop(ny. !mgcllsivclyconrracrirs sirh liccisd cont rrs t) conid.l rtr roic.t (Sc.- 704,4.I]u\in$r
<br />rnd Eurs\i,n C6dc: Thc Conkkrols Li.c.sc l-is do$ nor rtply i,.nowmr.l trop.ny who builds or imrrovd rhcr.on,
<br />ond who onlncF ntr s'ch p!,jcrh {irh fl Contackn( t liccnscJ lunurnr t,rhcContNtn \ Licctrsc t,rw).
<br />-l
<br />!ncrcmtl utrdcr Sccritrr-. a & I)C htrrhi\ rcNnr
<br />EOBf,IBS:CAUIENIAIION
<br />D[!I.AIAII!}N
<br />I hdrchy afllr Utrdcr pcinlryoi Fcrjury otrc oirhc t)lb*irg dcchnriox:
<br />-lhivc.ndwillrminr0inrCcni6c(rcolCooscnrroSclllnsurcioruorkcN.onllxN{idr.,stovidcdnnb}Scctnrn-lTOootlhctibor Cadc. for rhc pdi,rMmc of lhc wort for which llE psnil h hsucd.
<br />! h.rc.nd willnmi 0in sorkcii compcnsarion insura.cc. a\ rcqutcd hy s(r ion l7m ol rhc bkr G)dc. ior thc pcrrbnruec ol
<br />rhc $ork for wnhh rhis pcrnril is hecd Myworkcis conrpcnstrlion inntrlncc ddicr md poli.t nun'bcrd.
<br />I ccnify rhrr in ihc pcrfortu .. ofrhc $.rk f(n whi.h rhi\ ltrfrn i\ is\ucd. I sh0llnot enploy any p.rson in rn, 'nmncr${sbbc..trrsuDr.r...rblhcworkcrsconDcnsdionl0ssoiCrlilornirxnd+tocrhdirl\h.uldb..onEsuhj.tlhlhc
<br />*ork$(.omIfn$n povtiotrs of Scdbn .l7lD ol lh! trhor (bdc.I sMll. n,nhwnh.omtly wirh rhot ptovnions
<br />WARNINC: lililurc lo {curc *orkc( (nnpeildn,n $vcr]3c is u la*ful. ,nd shdl sublccr i0 crnlLycr ro.Tioriml F,rlris and
<br />civil fines un ro .nc hundrcd rhousrnn dollr* ($100.fi)O). i. oddirbn ro rhc.rsl olconlxnsatio . daruscs r\ pr.vidc r{tr rhc
<br />ili,i,'i1ililiill
<br />DPCLAAAIIO!
<br />I hcftby afrn undrr p.ndry olrc.juryrhar Lm lien$d undcr pmlisionofChoptcr 9 (smmncing wirh sc.iion 7000) orDivision 3
<br />ot rtc Blsift$ and A,ofc$i(,.s C.d., rrd 'ny lt.n$ is i. tull for.t drd .ficc'.
<br />G,
<br />-IUN t 1J+16"*"*, F.lu,rt^
<br />coNllf,I]cftoll,[NDlNli.&clNll
<br />I hcEhy afli,fr uhd.r ,rnolry or Frjury lh.t lhsc n a mhslrudhn lcndin8 r8cmr,or thc Frfor@cc olrl[ wo.k lor qhich lhis Imnn 6
<br />nsued (Scc. lO97.Civ.C.)
<br />dIIIII;ANI.DECIAEAI&N
<br />I lEr'6y alilnn undc. pcnllry otpcriury onc or'hc rollowinr dcclddn,n\:
<br />Dc,mhrion Pciinih Ashcstos Noliticltion ltdcrrlRcsulrrioos (-l irlc,l0. Pd6)
<br />-Rcquircd
<br />t llcrol'Nolifi.rlion
<br />l..dilirlnr rhcf.d.'rlr.Sul i.isr8ddnU r\hc!.\rctrrrrlnrc mr intlica6lclo rhislrn+cr
<br />rh.dLrr rl,! I r'.Nc rc rh' rrdl.ion dnarcthd rlrcah,vc nni)rmi'ion isc ro.o ply wirh.llCiryaDd Counry
<br />)frhis Cny!M Couniy lo cnlcr uDon rh.oilnrkcs,trd Srrt. tjus rclnrin8 ro nuildin8 con(ruction-
<br />rtxM nrnri,nrcd nrupcnv tur i.rp.cn. !ur[,scs
<br />Appllconl or Agenl SlCdroE
<br />PemilenrnE(pn )r 111
<br />Sp+h$ o f lntl
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Lile Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Translormers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinos (Hard & Soffit Rouqh
<br />Ceilinqs (T-Bar Rouqh)
<br />It/eter Release
<br />Flouqh h/ru/1 )I$ffi
<br />Service l\/eter
<br />FINAL 7,//z/a :r)6
<br />Notes, Remarks, Etc.
<br />Pole Bases
<br />\-I-E
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