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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDi]R I,ELCARATION
<br />I hcrchy n in. undcr Firlry()f p.ijury lh l mcx.nrtr lmnr rhc C.trlr0doN Liensc ltrw r.r rh.lollowiflS rcrwn (Scc70:11.5
<br />Bo\incs\ and Ptufc*io. C.dc) Any cily or Courry *hich rcquircs a psmir k, .on{fl.r. ,lrd, imlnvc, dcmlhh or rclat ,ny
<br />{flcrur., tri.r ru irs issu.mc. als rqlirc( lhc npplkini lor \uch ltnnir t, filc , qgncd sllrcmnl rhal hc or \hc is li.cnscd lU Uad
<br />t, rhc pblhionr .l rlr coir,.trtr\ Li.cnsLn kw (ChoDtc. e. Commncing uirh sc.rnrn 7000 of Division I ot rhc Bulincs rnd
<br />PmLssiorCodc)or rhat hcorstc h crcnpr rh€rctom3nd rhc hrsi\ r(r rh. nllcB.d cnnlprion AnyviolalionorSc.rhnT0]l.5hy0ny
<br />rpplic! tur 0 Fcrmir slbjccr rh. appli.rnrkJ,.ivilFnrlryornor.brcrhmlivchuftlrcddollarl($5m)
<br />L a\ ownn or rhc ,,rcrcny. or my cmpk,y.cs wilh w0rcs as lhct {nc .$orr.ns,l ion. will do lhc work od rhe nturm L\ mr
<br />i,rtcRlcd or oficrcd tu slc {Sc 7044, Buiin.* .nd Pm(c\rn,ns Cod. Thc Conr.mloi\ l,iccn* l,* d*t nor ,pdy b b ow.cr oi
<br />thc pmrcd, who hlilds or i'rprows ilEMn. ond who d.4s ruch{o himscll or tcr*lr or rhmueh his or lrcr o*n cmpk,y.cr,
<br />Irovidcd thar $ch impmwmna m mr inrcnd.d or oltu for slc Il hos.w. rlE buildiry or i,ryno{r is q'll wirhin onc )tr
<br />of $.plct6.. thc orncr Buildcr will harc rhc tturhn ol pmling rhtrr lt or .hc di1 mr build or in{mrc lhc lqsly for thc NrIlN o,
<br />L atownd oarh. t'opcny. anexclusiyclyconhcrins wirh I iccn\td .. trtr.roN ro lon(rucr llE Irniccl (S( 7ot4. Bunncss
<br />und Pnitssin Codc: 'lhc ConkrcroCr Li.cnsc hw des nol.ntly ro in owncr olpn,pcny who huilds or inpmvcs lhereon.
<br />aM *ho co.ln s for such roicls *irh ! Contudon r lEcn*d pu^uam fu
<br />'hc
<br />contr0dors Liccnrc L!w)
<br />I. crcry u crScclio
<br />Dlte O*ne.
<br />woR(FRS COiIPEN.SATT()N
<br />DES,AAAIAN
<br />I h..chy riirnlndd t.n,lryofr.luryom olthe nrbwirs dNLratnrns:
<br />-l
<br />hav. sid will nBinrrin a C.niif,alc oi Cotrsfll lo Sclll trsurc for *orkc6 .otrF.sarion, f,s ,rcvidcd for l,y Ssrion l?@ or rhc
<br />Lsbor Cndc- tr lhc pcrfortun.c.flhc sork fo. which tlE Pcrnrit is hslcd
<br />I h,v. dnd will mrinrsin wolkcrl compcnsariotr insumnce. us eqlircd hy S.d im l?m ol lhc lri,or G)dc. f{ rh. ldrdi.Dtrcc ol
<br />rh. work for which rhii Fnnn is nsEl My works co'rvEnelion insrrM.. .ad.r and Policy numbcr ecl
<br />/",,rv rhrr rn thc Jlcrliinu'rc.l rhc !u'l fi qhi, h rhn I'f'rrir -isnrcd. ! shallnor rnple!lnylcrsotr inonynrnmr
<br />!d lrrc. rhd if I sh.uld tnom subjGl lo rh.
<br />\tu11. fonhwirh .omrly sirh rhorc pro!hions..
<br />$ asr. txom uhird brhc wo cr\ $trrtrtrrdhon lissoicrlinnnir.
<br />*orker\ conlp.n\rri,'i F)vision\ olSccrion lTIrOolrhc lj}In (ix]l.1
<br />WARNINC: Flilur b {.urc qork r' sml).n\ari.n c.vcmSc h unliNtul shrll sublc.r ,n cnrllolcr lo ridi.al Ftulrh{.nd
<br />ro onc h!nlrcd rhousitrd dollaF (li1fi),(xxl). i. M.lirio ofco rrcnsrrion. drmrgcs as pn,viddd fd rhc
<br />Sccri(nr .1076 olth.lrhtr (id., i' crcn 0kldionry \ lic\
<br />lrla t t t
<br />^r,r,h,nr:)<-
<br />I hcrcby ilirm undcr prnalrynflerjfiyrhd I rfl liLrnwl undcr tolisionofChlplcr 9 (comnincinS with SNlion 70fi)) ofOilhion l
<br />or rh. Bxsin.s ,nJ Pofcsions Conc. and my li.ctr{ is in full nncd md cr'rmr
<br />D c c c 9(g57oc7
<br />t,"," l\4at r/
<br />I hcrhy rlliirn undf Jlnrliyol F Jury rha! rhcrc t a con{tucrhn Ldnrg iEcncy lor lhc pcrlirmrNc ofrhc Poft for which lhh pcrni! n
<br />i\suedlS.c -1097. Ci! C ).
<br />A.ITI.ICANIDECI.ABAIIIIN
<br />I lrrny aJtm undci Fnah y of p.rjury om of lh. follo*ing dekll n trsl
<br />Dcmolilion Pcrmils Ashcsror Norific0rion Fcdcral Rcgul.rions (TnbrO, Pan6)
<br />-Rcqutcd
<br />krr.r of No(iakari.n
<br />I asrc ro 6rply wi$ allCily!dcou.ly
<br />lrivcs olrhh Ciry !r.t Cou.rylo.ni6 ulrn dr
<br />""", Lla"l q,lg
<br />//
<br />/7
<br />L.n vrhor,hc lcd.mlrc8ulolinnt rprdins a.hcn,^rcnr.Lluc n.r,rnLE$lc I'
<br />VI Rnilr t\r lh$c rcld lhi. apnlrJrii,n.'n'l ilr. rh r\c,t,\c nloaturnl Ncomcr
<br />.TIFJA cs Md sr.rc ljws mllrins r.l,u'ldrns con.turll"n. rrl h.'rhyadrh{'/u EI,rc\cFl
<br />f ,
<br />" ^n -*a p.,p"ny r,,,." "., n-€rr:)r_zlb_
<br />^Dpric.d
<br />orAsmr slBnarun < I " V
<br />ermir*namerprinrr:x / Sullnn SuMJ
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Liqht 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 i lzr\tB
<br />^^tA(A)Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soflit Rouoh
<br />Ceilinqs (T-Bar Rouoh)
<br />Meter Release \g ^4\o
<br />Rouoh
<br />Service Ir/eler cl(t9,,q"d/ltL
<br />Notes, Remarks, Etck
<br />ut+,l I
<br />-t
<br />I
<br />FINAL
<br />landcir Ad E$
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