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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS ID/SIG.COMMENTS
<br />Site-Work
<br />Underoround
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Founlains
<br />Sions (monument)
<br />Lile Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFEB
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soflit Rouqh
<br />Ceilinqs (T-Bar Rouoh)
<br />It/eler Release
<br />'D)t4 I r4ru,*,a LarY)Rouqh I
<br />Service lvleter UI
<br />au^r+l/,W1)FINAL ,I
<br />Notes, Remarks, Etc [ l
<br />OWNER BUTLDER DELCARATION
<br />I hcrcby nllrnr undcr pcndhy.l pcrjury rhat I m.rcnnl rtu'n thc Co r!.rorr Li.cn{ tjw ior rhc iollo*in8 t rvin (Scc?oll5
<br />Uusincs\ lnd P('f..rt,n Codc): Any Ciry or coumy which rcquitcs a Fnnir ro !!n(rucr. ahcr- inprovc dcnnlish or torln ,try
<br />srucrxrc, nrsrlo irs hsurmc. so r.qunc( dc lpplic0fl nn sichlrnnir Io filco\isncd iur.mtrt rhrlhcorshc ( li.cnscd puNuanl
<br />t. rhc poyisn,n\ of rhc Controctr's L.i$n{d rjw (Chapl.r 9, Comh.ftine wiln Sccrnrn 70(X} oi Division I ofrh' Btr\in'rs rf,d
<br />Pn,L\sions Codc) or lhlt h or\hc iscxcmpi lhcrcliomlnd rhcbusil f(r lhc lllcgcd dxcnrflion AnvviohrnrnolScclionTll:ll5byrny
<br />apflicrnrlbrapc.n,ir\uh,c.hlhc q'plicanrt.a.i!ilP.mlryoi ortrrEihanrllchundrc{dolhr\(S5u))
<br />L ns ownd of thc prorEnr. or ny cq)l0yes wnh ,!scs !r rh.n crc ..mPcnsri,n will do rhc q'ort and rh. stnriN is nor
<br />inr.ndd or ollcrcd lor $lc (s.r.?1r44. Busincs\ lnd Pn,rcsions Code:'lhe Conta.tt's LiNnse ln* docs nol aPplr ro an own*or
<br />rhc pmlsny *lh tuilds o nwoEs rhE on. arn *h dEs sEh tult iin$clror htrullor rhbrgh his or hs own edrlovNl
<br />F,vidc rhrl srh in{n rcmnrs m nor inrcnd.t ot oficrd lor €k lt howcvtr- rll l,uiuing .r invmrcnEnr i\ eld wilhin orc }te
<br />;l corll)Lri.n, rh. (Nrcr Bnih& will hatE rhc bu cnoiDroviryrhd htorsh.did nd huild or nnPmvc lhc pmli.ny for rhc PurFc of
<br />L asosrer ofrhe pn,lc y. unciclusivclr..nka.ri,rS*irh liccned conrrdoE lo.onsrrucl lhc pojcd (s(.7044- BNmsr
<br />ond Pn,lssb. Codc: Thc C.nrracttr c Li.ctrsc L0w del nol !pI,ly r, M osnct oanloP.ny who builds or innrovts rhcrcon.
<br />..d who conrEd\ n, such projcds rnh a Contrcro(t lk.n(d pusuxnrh rh. conra.rois l.icen{ trw)
<br />I mcxcmnl undcr Sc.ri
<br />I h.'chy rlftf, unJd nctrrllt.l n 'iry
<br />r hlrc ind will'nlinrih rGniicare#Con\cnrtrS.lIltr{rcli)rsdr[.'r.orl,cfslrior.r\In)!nkdirhySkri(r:]7(()ollhc
<br />Lltx, Codc. lor llrc tqfomN or rh. wo* for wtich rhc Frdr c ksNd.
<br />-l
<br />Mvc rnn sill @iol.i. vorkcs cor{snrarion itruEmc, as requiEd hy Sccliotr 37(xl of rh. tibot Code. fot th' PcrlornM o'
<br />rhc work tor whth rhh pcmil is issued My worl(cts comrnsalion insuhncc cadcr and Flicv numbcr m:
<br />Il)li.y Nunr6.r:-lipirc\:
<br />l&n,fy rhd in rhc p.rformftc oirhc work ld whi.h rhi\ p.rnrir is is{cd. I \hall no!.nrplo, any pcr\.n in rnv nranNr
<br />b ns ro bccom subjcd ro rhc workcn conlcnsuri{n1 laws orC.lilhmil and asN rhrr iil \houl tNonr suhrcl rorhc
<br />sorkc^ coDp.nsdioD ptuvi\btrs olSeclion:l?00 ofrhc Latxtr CoJc.l \hrll nrnhwirh contPly *irh rho{ [ovhion\
<br />\VARNIN(; li lur. n) EUrc *orlc . rrrfsrr d,vcrilc k unl.ptul. anA fiall \uhj.cr l cmPhys k, rimiril Pcm[h\ and
<br />civil fiic\ utr k, oN [trndrr{i rhutr\xtrd
<br />Sc.rn I)7a.lrhc l-rlinCixlr.i'i.,c{
<br />lrx)r. tr, xrl,l r r t, rl,c .o( .1 Ntrtrrltion. da Dgcs r{ pmvidcd for rltc
<br />DI(1,,\R,\'tI()N
<br />I h.rhyaffir undcr rcnalryoipcrjury rhnr I.m liccn n(lcrpft,yi\ionolChrnrcr!(cofntur. rEwirhSc.rionTm0rolDivilirnr.l
<br />ol rhc Businc$ md PofcasiorN Codc. ud ny li.cn* in lulllorcc inrl.lL.r
<br />(aSEIBUqUOII!!DI!I(iAGIX.C1
<br />I hcrcby al6i,n uMct FnahyorPcrjrry rhd rhcrc h a consrtucri,n L.din8 4crcy attr rhc l,crronnrrc otrhc sork f'r which rhi\ Fr''il n
<br />issucd (Scc :1097. Civ C.)
<br />APPLICANT DFCLAIL{TION
<br />I hcrcl,y aainn uMcr Fnally of p.qury o.c of lhc rbllowin8 d*lngr ions
<br />Dcrmlirioo Pcro(.AstEstos Norificarion F.dchl Rcrulolions (Tirlc 40, Pan6)
<br />-Rcquncd
<br />Ldl.r of Nolif$li,.
<br />I(/al IB
<br />DATE
<br />lrtrJ.r'. \,lJ'"*
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