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ELECTRICAL.INSPECTOR BECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDI]R DELCARATION
<br />I hcrcby,trtrm undcr p.nalry or pcrjory rhir I m eicmpl li.m rhc C.ntmclos l-tcnsc t,w for lhe follo*ins rcasn (Scc?01,.5
<br />Arsinc$ and Pr(r'cssion Code) Any Cily or County whi.h r.qxi6s a J.r. r ro .onsdcr, alkr, imprdw, dcfrrirh or mpLn any
<br />sltudurc. prhr ro its tsuancc.0lv, rcquncs thc opplicnd for su.h Fnnn ro ika siSncd {nrcm lh.l lEor sh. i licenrd pu*ua
<br />lo lhe rorhions orthc Contacror's Licc.scd tjw (Chaprcr 9, Conmcncing {irh Sccii.d 7O(D ol Dilknrn 3 .frhc surnrs and
<br />Proic$ions Codc) or lhal hc or shc t cxcDrpi lhcrcfrcm and rhc ttr$is ror rh. ollcgcd cxcnlpri.tr. Any v,olation ofScclbtr 7011.5 by atry
<br />4ffiffi ;ffi."*,#--*ffi ffiffi"-;inn**",.,
<br />rhc J,mpcny wk) boilds or iqmws rhcd'n. dd wh. d6 skh sorl himsclfor hc^clfor rhmugh his or hcr o*n.rplorc.s,
<br />providcd rhi stch impmwmnrsm mr inrcn& n oficrcd lorsrlc.l( ho*crcr. rhe huirdiq or imrmEmnl issUwitiaom 16
<br />olco'.plcrior rhc owrcr Buildcr willh'rc rhc burdenolpovirS lh lt or shc did nor huild .r nnpi(,vc lhc potmy for rhc l,Urrx's of
<br />l- soqmrnfrhprt,rdy.drcx.lusivclr.otrtrcrin8wirili.cn\cd.ontrctxt,.oD{tu.rlhcpn)jcd(S.c7(},14.Br,i"r$
<br />a,i&.rssbnCodc:lhcConrrcnr'sl-iccn\cl,rwdocsrot0t)r'lvro.*nc!oipropcnyahohuildso,tnpn,vcsrh.'.otr.
<br />*ho.ofur(r\tur\u.hB,lc.N(irlrrC.kcrtr(\)l'rrn\rlllur\utrrbrhcCotrrr.rtr'\1.'.rtr\cLr\)
<br />lr
<br />V I
<br />I hcicht rlli'nrrn,lcr pcMlry of|[rlurtotu olrhc rallowi
<br />PolicyNun$cr Erph\
<br />I.cdityrhrinrhcncrrnnnurcolrh.sorknn$hichtlrilt^-rniri\isnErl.Ishrllfrrctrrloyanypcrvn,inrtryornnci
<br />o rsrobr.oif, \uqcd brlr w.rkc^' .onrlfn\d 6n lrw\olCrlif{{fir. rnJ xErL{ rlrrifl \lr,uu h.cotrr\uhrc.r hrh.
<br />*.rk.rs.onrFtr\rridrpflrvni,,nlolS.dn,n.l7(nofrhclrhtr(t{c.lshlll.lonh\irIcon t$irhrl$\cpmlis n\
<br />WARNINC: lj{ilurc to sccurc wo.kcn
<br />::r'f.'fiaTiH
<br />conDctrsalior covcrtr!. is unlawhl. itrd rll suhjcct rtr cmploycr Io crimirrlrEnrliics and
<br />dollffs (Sl([.uxr. tridr ro rh.
<br />Ihcrcbtrfln'nuidur.rhyofFluryrhrrI nli.{.s.dund.rtnovi\i{nrofChaprcr9(onnkncingsnhSc.ri(
<br />or ihc Busircrsand thilssn,n\Codr. d nry licensc is ir tulllnr.u xlcr'iicl
<br />CotrtE.lor:
<br />CONSIiIJI:IIANIEIDINC-AIiIN.CI
<br />I h.rchy affirm uM.r Fnrtyofp.lurr rhar lh.rc k aconsroction lcndin8 trgcty fd rhc FrfornBn.e ofrhc work Lr whi.h rhi\ Frrir i\
<br />hsocd (S( .ltr97, Ci!. C.)
<br />A.TIIIIANLDECITIBAIION
<br />I ho{ny alilm undcr Fnalty of pcrjury om of llrc followine dftlur(ions
<br />D.nnlition P.mirs Asb(ro! Norificorion F.ddrl Rcsubrn,ns Oirle.r0. Pan6)
<br />Rc!uiBd bnf of Norificarion
<br />h*d;hcfcdcmlrcSulolions E8ardirg .sbcnos rc r'rtrlr* nor,rpl{ahlc lo
<br />rc,.ad rhn lIplaart,nond slrrcihir rhc ltDvc nnonMrion is corc.r
<br />rudion. u\i hcr.by ouihorize rcprecn!
<br />rtx,vc nEnri,,nctl p.orcny lhr in\iccrion
<br />Appli(nnl or Ag€nl Si*nalrN tlix
<br />I rxret,i{'plytrirhallCi,y rn'l C dtrla
<br />rn's "r,htr ci,vrndcou y,icdrundn,hc
<br />"^,l4fu1fu)){
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lite Saf ety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />fqqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />ft/eter Release
<br />Bough
<br />Service [t/eter
<br />FINAL /,27-/8 J/elaz ,fr/
<br />Notes, Remarks, Etc
<br />Translormers
<br />_l havc ad *ill Einrain a Ccniiiclrc ol Consc ro Sclf.lnsur. fr. worksl com,E.snrion, os lmvidcdforhySNri.fl17(x)ofrhc
<br />tabor Codc, f(tr rhc p.lfonMmc ofrh. wo { for whi.h rh. p.mn ! i*u.J.
<br />I hrvc rnd sill @inr3i. Macrr' conpcn\arion inslrarc., as rcquncd hy Sccrion l7O0 ot rhc trh.r Code, for rh. lcrfolfunc. of
<br />rhc work l uhi.h rhis p.rnil is issu.d. M y work.^ ..nt nsdr ion inslrsn.r crid ,rd F,licy nxnrbfi ml
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