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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.OWNER AUILDER DELCARATION
<br />I hcrcby nfilm undcr F.0lty oi pciury lhal I or cxcnrpt ftunr rhc C.nlrrcton Liccnrc Low ior lhc lolloqiry rctr$n (Scc.roll.s
<br />Burin.s and Pmlcsion Conc): Any Cily or Counly $hich rc{un$ ! p.rmil ro c.nrlBcr- rlrcl in'prolc. d.n,li\h or (p!t M! -nru.rur.. l]rio h it hsund. als. ,.qriE\ rhc lPtli.lir ttr slch Fmir b file r sign.d iaicftni rh,r hc or !h. is li.cnscd punuMr
<br />ro thc povisn,ns ofltr Conlraclors Liccnscd tjw (Ch,prci 9. c.nnkn.ir8 wirh Scctiotr ?(xn oi Divhion I oa rhc Br\incs otrd .
<br />Pdt$ions Codc) or thhl h.orshc iscrcflrpt lhcrclrc ond lhc h0sis r'or rh. nlle8cd cicnrlion Anyvnndionotsccri.nT0-ll5hrrn,
<br />l,Ilicrnr ror r Fnnn suhjNr\rhd trppli.rnr u scivilpcnrlryolN,r nDrrhro fivc huldrcd dollar($5fi})
<br />-1.
<br />a\ owrcr .f lhc Dropcnr. or ny chployes sirh wu8cs !s lien sb co.rpen\lrion- *ill rt , rh. wort ui rL {turuft i\ tro'
<br />irftftLd or dflahd lar salc ( Se.7044. Busi.cs dil It fcsi,ns Codc Tlr C.nk*tr\ l-i!trsc tjw d.cs not ll,!l, to an owncr .l
<br />lh.pmpcdy *ho huililsor inDmvcslhsen. ond who des such "na him\cllor herlcllorlhrou8hhnorhcrownenrploycc\,
<br />pmvklcd rh \uch nnl)mr rnrs dc N inr.ftld d ofiikt f(n elc. ll bR.ec,, rtr hriuihE or inPniwnrnr h $tl $irhin.'r )rr
<br />ofcrrrlcri.tr. rlr Ow f Boildd will havd rhs lrrd.n ot ptuving rhar lr or \hc dil ior buill o. itu tu\t th. tmFny rDr rh. t'ury\c of
<br />l. rs.qrcroflh. roF1y, d'ncr.lusivcly(ontrrin! wirh lic.nscd contd.h\ lo.otriru.t rhc pmjc.l {S(. ?o4,r. Busin$\
<br />rn1 l!h'ls\i Coic-lh.A,nrrocttrsl.iccn{Lrwd.csnorrnDlyro!nos1c!ofprorcrryuhohuikkorin,prov.\rhcr..tr.
<br />itrd who coflu 0cr br srh pnrrc{ts wirh a O r0.ro(9li.cnscd Nnurnr ro rhc Contructor's Liccn\c Llq)
<br />I rm cxcmtr und.r Secrio
<br />]YAAKD&T:g}TIIENIAITN
<br />DLCLIBAIII)N
<br />I hcrchyrfinnu dfi r( rlrtofNrjrryotrcolrhcrolhwingJc.lerridrs:
<br />I hrvc d srll nuirrnhr Gnill.nrcolG iscnr ni Scll lrrrrc n, workcs coDpctr(rnnr.
<br />If,h.r Codc.larrhcr.nnrnr'r..trlf, sork ntr$hichrhr ncnnir is n\kd
<br />as Drovidcd lor tly Selion l?0o of rhc
<br />rhc Labor Code. for rh. rdfomne otlhrrcrnd willmrinlaio sorkcr{ comEnsrlior in\uriNc. n( rcqn
<br />drhc +1,t rirr whi.h ihi\ Frmil t nsucn Mrtr rlcK' corll\Jr r,n i',tj,l-<- f-tt ng
<br />3/11.
<br />I ccdililhar inrhc p€rlontunccofrhc work for *hichrhh p..nir is i\srcd.l shr!l .dr cmpk,y trny lcrsDtr ir rny mrnNr
<br />rrr\n,bcconrsuhJ..rrorhctrorks{mnDcn\ar$nh$s.fCnlinnnr.rtrd:l!rccrh|(ill\houldbccoDrsu6jccriorlr
<br />*orkcr' coml]ctrsJrion proision\ of Sccr ion l7{D of rhc hn, ( qlc. I rtull. hnhsirh comnl, wirn rfixu pmli\ids
<br />trll lnr\ up b onc hundrcd
<br />:::-''fli'i'
<br />tr orkfi $n,r,c \xrntr' .o\r,r(c
<br />l't"]l9{"'1"':''w'
<br />suhlcd in.n{'bycr lo siniraLpcu,lrics !nd
<br />/)---z
<br />LI(ENSIU) C()NlRACtlrl{
<br />UIILI.BAIIQN
<br />I hcrchy ulltn undcr pcnulry oi ncrj$y rhd I sm lien$d und.r previsioo.rChllrcr 9{connmicing wirh setion 7ux, oll)ivkion l
<br />of lhc Busi,rcs md PrcfcssiorN Codc. and mylkcnsc is in tull fore !dcl.lcct
<br />C to ? to --t
<br />flrrfrE
<br />I lrrcht {fln'n ufttdr pcnd!ryoflcrjuryrhtri rhc'c k...idtdir,r hndiigrBcn.y liJr rhc tcrlbnnoncc ollhc $orI ior *hich rhis !crn,ir is
<br />issucd (sN. 109r. civ c.)
<br />Lcndcr'sAddr.ss
<br />-
<br />l.rdil!rhrr rhr lidcrrl 'c8!krn,n\ rcgdd E r\lrro\ rcnn,vxlrc tr.rnt!li.nhlc t,nrisir!!.cr
<br />nrdy wnh all Ciryu.d Counry
<br />.l'h^ airy md Coutrry k, cnrcr urnr ihc
<br />s[tr I rq
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Translormers
<br />Torqueing
<br />Air Conditioners
<br />Bool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilin gs (Hard & Solf it Rouqh
<br />Ceilings (T-Bar Rouqh)
<br />lvleter Release
<br />Rough
<br />Service lt/eter
<br />Notes, Remarks, Etc
<br />COMMENTS
<br />Pole Bases
<br />i.\4
<br />Sub-Panels
<br />'7 -17- i .Q I
<br />7,11- t l
<br />FINAL
<br />A.TTLICANLDECIAAAIION
<br />I no$yafimundcr pcnaltyof Friury om of lhc follo*inB d(lararion\:
<br />Dcmlitio. Pfrmirs.Asb.sros Norilic io. F.dcral Rc8uhiions (Tirlc 40. Pd6)
<br />-Rcquir.rl
<br />t llcrof No{ifaatiotr
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