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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE OWNER BTIIT,DER DEL(]{RATION
<br />I hcEhy afiirn undcr pcnllry of pc.jory rh.r I d'n cxcnDr linnr rhc Cont.crots Licensc Llw,or ih. rolk,wnE rc0srn (5(.?031.5
<br />Itusincs lnd Pofession C.<lc): Any Cily or counly which r.qutcs ! pcrmn ro condocr, ahdr. inDroq. &nmhh or Enan ,ny
<br />{tucrurc, p.io . ns issu,n..,,ho rcquncslhc rtpliconl for such permil b lilc a sigred shlcircnr that lEor ihe h licttri.d pusunnr
<br />ro rhc Dmvhions ofttE CoorEcror's l.iccnied Ln* (chryrfi 9. Commmins *irh Sc.lio. 70m 6r Oivi\ion I ofllc Bu\in$s and
<br />Protcsions Codc) or rhd hc or shc h cxcmrr th.rctunn lod thc blsh ntr rhc ullcgcd cxctrrp'ion. Any viol0lionofScdt'n70.115 by rnv
<br />altlicr for n pcrnir sublcch thc applicanr roacnilFnahyornor m.rc'httr lirc hundrcddollar (S5m)
<br />-1.
<br />0s oNrcr ot rhc nDFdy. .r nly cnll)loyss wnh w!8cs os thcir sle comFndi.n. wrll d. rhc tr rk ad rhc srturur. is to,
<br />inrcrt.d or ofi.rcd ror slc (Ss.?044. Busincs md Profcssiofls Cod.: The conrMrtrt Liccns f!* doc\ nor {pply lo atr owrc! of
<br />lhcpmncny who tlilds or imrrett rhm$n, snd wb dftr luchw)tk hi scllorhcrcllorrhR,xlhhhorhdo*ncmllolt$.
<br />pn,lidcd rhar su.h nn hEmnt m m'r hrc cd $ ofrcrcd for eb ll h,*.vr. rlr hxildinE or irttorcm.r is eld *irhin otu F
<br />of.o,rrlclion. ihc O{ncr Auiklci $illhorc rhe tulcn ot provins ihri lr or shc did nor build or imomrc lhc rmFi, for !h. purlx,$ of
<br />I. ,r .am! or rh. [o!cny. am cx.lusivcly conlBcl ins $irh liccn\.d .onta.roE lo .onstrud rlE l,ojccr (Stc 7ol'1. Bu{nc$
<br />and PnnLs.bn Codc Thc Coitacl.fs Li.cnsc Lawdocs not 0pplylo ro owncr na ParFny who huildsor inrProlcs rhercoi,
<br />.nd who co mcrs for slch pmJc.( wirh a conrtuio(s) Ii.cnscd |)usu to rhc connlcroi\ Liccn* hR)
<br />-l
<br />!u cxcnrpr undcr Sccr
<br />Drls - O*n.r:
<br />woRxiRs coMPENslrarN
<br />DEI:IAAA.IIOB
<br />I hcrcby affi m unncr pcndrrdtp.rjuryoft orrhc followire dc.larations
<br />-lhr\r
<br />d will .Einrain tr Ccd ituarc of Con{.r lo Sclll trsurc f(tr *or kcs .o.Itn\rr io.. rs 0rcvided lor by S(iion .l7m of rhc
<br />l,lhor Codc. to! lhc pern,runcc otrhc w.ik rd vhich rhc l,tnnil is isntd.
<br />I hdv. ind willmrintrin workcri .onDcnNliqr ins!r!!cc, !! r.quir.rlbyScdnn!17(X)otlhct:'horCodc.forrhcp.rlo Mtrccot
<br />rhc w.rl ror whi.h rhk pcirnir is is$sl. My *orlcG compeosal ion insunn.c .micr and r{licy nu mh.r tft:
<br />PolicyNx rhcr:-
<br />-l
<br />ccnirlhat nr lhcrcrr.rnun.corrhc wor* Lr whichrhis pcirnil t nslcd.l \h,lln.r c.Vk,rnnylErson in otryo'aitur
<br />$ os lo bccom sxhi{r t' rh. wodrr cornpcns bn llsc of C.liiunix. dndredc l[d iil should tecom sur,jd rolh.
<br />sorkc^ comlcnnnion tmvirions oiSccrion.UOl)oIlhc tih, Codc.l \hall. fonhsilh conPly wilh Iho* nn'visnrns
<br />WARNINC: Frilurc hr *.tri. *.lkcN corpcnsdrion .orcmsc is unhstul. Md \hall {b]cct arr cnuloycr lo .rlnin.l Nnrlricc n
<br />.ivil ,ii.s up k, oft huMrcd rhous0nd dollar (Sl0o.mo), in trsrion. d!rogds ns providcd r'or lhc
<br />,r" Cod.. i.icrcn andarrorrcy s lccs
<br />,rr", 5h-Y
<br />UECIA8AIIAN
<br />Ihcrhyafln'nundcrlcn.llyolpcrjurylhlrIamliccnEdundcrFovi\nrofchlDtcr9(cohmnci.!wnhsNrn,n?(xr)ofDivnion.l
<br />ot rhc Arsin6rand PbfcssionsCodc. and nryliccas is in fullluLc rtd.fla.r
<br />os2
<br />I 3l)i@L]
<br />I hercb, amrm nnd( Fnaxy or Fdury thol li.rc n a coNrcthn leDdins ascn.y lor rh. lEnornEncc of lte wor* ro. which rhis Fmil is
<br />nsucd (s( 1097. civ c.).
<br />| .ndc"( Nsm
<br />-
<br />trnJ.r( Addrc$
<br />-
<br />Af]IICANLDECLAXAIION
<br />I h.iEhy ltlm ufrlcr r,cnalr y or n rjury onc .r rlf hllownr8 dcclml ions
<br />t).'tuliri,,oPrn +AshcslosNolificoln,n Ftderal Rc[Uhrnnr(Tillc.10, Pnd6)
<br />l{cq tcd Lcrr.r,'l Norili.rrnir
<br />l..dllJ rhrr lhr\. ru'l rhn rrplir inr i\..nccr I aSrs tocomnly $ilh rllCiryrklCootrry
<br />.',li m.s rrlsrxrd Lx*\ r! ntr,!
<br />atnlc Drnrioncd lrropcny inr iN
<br />Appli.!nr or ,1genr SiEnnIur.::::?4/;::-
<br />Site-Work
<br />Underqroundr.,.lr\5 59 c\tAts Itt,Co"l*a .V
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains sttH 6\2?\\6 Alh|\\P*t c{c"\ bo,35 \ eq.r? $vle
<br />Signs (monument)ro dul. bo4l'ye*
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding IUFE&4/14r(th<s1.,
<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 />Ceilings (Hard & Soffit Bouqh
<br />Ceilinqs (T-Bar Rouoh)
<br />It/eter Release
<br />Rouqh
<br />Service lrleter
<br />FINAL ht /a ttv 5\frb
<br />Notes, Remarks, Etc
<br />ID/SIG.COMMENTS
<br />-liinircr
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<br />-lccriiyrhlrrhcltdcralrcgul.rionrrg,rdingasbc{osrcrmvnlm.ollpplicrhleturhispojccr
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