|
ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />l. N owicr of rlr pnD.nt. rnr .rchsivcly coftaciing wirh li.cnscd conrndo^ h .onn rud rh. Itr,/.cr r Scr 7O'1J. B!{nc*
<br />ind tnrixsbtr Codc: l-hc Conki.N's t-iccn\c l-rq do.\ nor npplt b an o*ir of pR,t dy qh,, huild\ or inrltrcs rfui$tr.
<br />rnd *ho contacl\rir\uchpr!.cl\wirh!Co rck(oliccn\cdrur\ua k,rhcGnlrrcktr s l-iccnsc t,iw)
<br />,.,"t!1"
<br />I hc,cbyaffi rmindcr ranalryoiFrjuryonc of thc followinS dcclu ions:
<br />I hlvc and willmaintli. a Ccnifrarc olConEnl lo s.lf-lnsur. ror workc.s comrcnsrion, as
<br />trkn Codc. aor thc Frfonmmc ol lh. sork for whi.h rhc pmir L icsucd.
<br />d lor by Sccliotr:17(xr.lllr
<br />lhrvc,nd will nrainhin *drkcri conlP.n\rlbn irerancc. ar rcquncd hySccln,n:l?(x)ol lhc t hor Codc. turhlFrr.trtun.cot
<br />rh. work lnrwhichrhn pcrnir i\ isued M)sortcr comrcnsalion in\urancc mri.. ul Fnicy nunrhcr !re:
<br />work ror uhich rhn Nilnil i\ tsucd, I shrll nor cmpk'y lny p(rv,n in lny nrtrn.r
<br />nrpcnsrr n liw\of(slifon,ia, and rgrc rhar ifl diruld h...rm suhj.{r Iorlf,
<br />i.tr l?'I',,rrhc Lhr' (iiilc. |\hrll '^nhw h,.n,flyw hrhc{frn\AFn\
<br />W,\llNlti(;: rrilurc b {drc sorkr^ oi,p.tr\dn covcrrlc is unlx*tu]. rtrJ \hrll suhjcct rn .tr1d.rcr
<br />*"*V\i#1,6''
<br />I hcrch] 3rfi,n u lc, Ilcnally or lcrjury rnrl l {nr lianen undcr rhlis
<br />or rhc lrusinc$and Pmlcssions Codc.ord nry liccne is h tullbi.{
<br />orChrpt$ 9 knmNrcir! wilh Sccli,in ?fi1) ofl)ivi\i{nr l
<br />ATTUIAXI.IIEIIII.BAII!]N
<br />I hddryuiimu cr pcnulry ofpcrjury on. ol rhc rolhwio8 dc.larari s
<br />Demninnr P.flnn$Asbc(os Noti6c!tio. fad.rrlR.Bul io.rlTnlc 40, Pd6)
<br />-Rcquir.d
<br />Lcrlcr of Notificdi[
<br />,din8 a\h$los rcmv !rc not applicuhL ro rhn pojsr
<br />. rhir (hc rtix? nnff ri{n, ncotrc.r lrgrct,
<br />ahrvc nrtrriomd pmrcny li, nslsrion
<br />ruclnrn,a hcrcbrnol&,nzc
<br />tt) \tt:
<br />(/biu'"
<br />Site-Work
<br />U nderground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab i Floor
<br />Eqding / Grounding / UFER
<br />Translormers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilin gs (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rough)
<br />Rough
<br />Service IVleter 1r
<br />FINAL I '-hAl)g,,ffi lEfi
<br />Notes Remarks Etc.V't -tv \:/)
<br />OWNER BUII,DER T'E!,CARr{IION
<br />I hcahy aifinn lnder I'cMlly.t pcdury lfial I m cxc'ntr fmh rhc Conr0cr.^ Li.ctr* bw ror rhe follawing rc.son (Se.?011.5
<br />axsinc* and P,of.ssion C.d€) Ant Ciry or Counry which rcquncs r plrmir to conslrucl- altci impmve. d.nmlish or rp any
<br />slru.turc, prior b irs isruun.., aho rcrluir.s rhc +rlicanr for slcn rEmir ro iih ! sisncd dalcftnr lh0r hc o, shc is li.cn*d pursanr
<br />!o lhc rmvhn,ns oI th€ C,nrEclols Licensd L3w (Chopl.r 9. comnrtrin8 wnh Scctiotr ?cm of Divniotr 3 ollhc Businc$ and
<br />PmlcsionsCodc)orrhrih.o6h.iscr.npr$crctromlndrnchoshforrtuallcscdcicnutrn.AnyliDlari.nofSerbnT0.llthylny
<br />Itm,llcrn' lor ar.lnnr{brccrcth. spplrrnrro dnr'lf+mlryoln.rmrrhan 1tr. hdtrcdJ.ll,! '1r0orltl \lll, \oeftr orrh. rr.Itny, 'tr mrcmnloycc\ {irh tr ascs !s lhet soh compcnsdion- willdo lh. sort 0.d lhc $ule t nor
<br />intc cd or oll.Ed ro. et {sd 7()ll4. Busin.s lnd Prclt$i,ns Codc: Thc Co.trctois t-iccnE Lrw dds rcl qdy b d oNn$ .r
<br />rhc pmpcny *h) builds or iqrorcs rtENn. rxl who dNq skh w.rl hini.lfor hfislfor rhmugh hi\ or hc. .wn .nlployc.s,
<br />t rcvid.d rhrr skh imprctnEnk m nor inrcnd.al or oficE-d fin sh. ll howa. rh. huildnB or inlroEmnl h sU rilhin .m )rd
<br />dt complcrion- rhc O*nc. Buildo Nill h!rc rie t rdctr olr,!i,g thd lI or sh. dd mr truikl or iiPnM lhc r/Dlsy ror rh. td,rrE or
<br />Li..nrc Clas:-Licenrc Numbcr:
<br />-
<br />Dsrc ('orlncror.
<br />CANIIAICIIONIEIDING.AGENI;I
<br />I hc,cb, amm nndcr lEn0lly o, ,crjury ri.r rhcrc h o con(rction lcndin8 a8ctrcy fo rhc Frfoirm"cc uf rhc work lor wNcn rhh rErnn is
<br />hsucd(SN :1097. Civ. C.)
<br />Lcndcr' NJm:
<br />L,1dcr', Add'r\.
<br />ADpli.onl or A*cnl Si*nnlun
<br />IVleter Release
|