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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE tD/stG.COMMENTS OWNER BUILDER DEI-CA'IATION
<br />I hcRby afitm undf ,.D0lry of perjury lhd I 3m .rcn r tmo rhc conoacroF' Licns tiw for rhc lollowir8 rcasn (Scc 70.11.5
<br />Ausinc$ lDd Prolcsion Codc): Any City or Counly whah rcquircs ! Ilmil lo onslrucr. altcr, nryrove, dcmlist or rpaimny
<br />ntucrurc. ritr b ns issuaN. al{ rcqriEs rhc al,plicanr for such pcmir b fi|. d rigtud turcftnt rhnr h. or sh. is liccns{ lluNnnt
<br />ro rlrc rDlhions of rlr Conrncrols Lienscd LIq (Choflcr 9. ComnEncins sith Sccrion 7{r ) oa Diaision I ol rh. Busincs nid
<br />Pmr.sions Codc) or rhal h. o. rh. h cr.npr thq.rn,n ud rh. ba\is fff rh. alk8rd cxcmfln,L Any violalion ofSNlion ?011.5 hy lny
<br />applic0nttbrop.irnilsubicctslhc.pplica.rlor.i!ilpcn.hyolNInDElhan6!chondrddollars(3500)
<br />I. ^ .sn(olrhc pn,Fny- or nry.nlr.rtci *irh saScs as rhcir s,lc conDrnsarn r. willdo rhc work rd thc slrutuE is mi
<br />i cndL\l oroiicrcd f.r $lc (SN.7u1-1. Busincsnnd Pi.nsi( ! C.dcr Thc Contu lor's Licctra l-iw docs trot .prly ro !n owncr oi
<br />rhepmFny who hu ilds or nnprows
<br />'her@r
<br />lnd *ho docs n'ch w,i( htnscltorhcrcll orrhoush hi\ or hfio*neq)lly.rs.
<br />Eovid.d rhar su.h inDrnrmnh e r, i.rctrdcd d ollcrn rd{1..Il kwcv.( rhc bu ikl irU .r nrpiovc nrnr is bkl*irhin,'m yrr
<br />ofLlnnpkrir..rhrOwmrBuitidwillhavdrh.hordcnoffl,io8rhdhcorshcdid.rhuildorinlpn,wth.tnrlEdyforrh.Nrynco,
<br />l. arowncrolrh. F)pcdt. r,ncrclu(ivcly contscri.g sirh lico{d conkkron u d \rtucr rh. l,oFcr (Sd.7044. Buencrs
<br />a PnlissionCodc: Thc Cont.clols Licensc ljN
<br />'locs
<br />nor ltlr'ly to !n o*.cr olFopcny$h(, builds or imroki rhcrd,n,
<br />and wlk, conh.h fur skh t,rcjds wnh , Conrmcro(s) licen*d pn*mr r. thc Conrr.rois Lic.nsc h{).
<br />I mcrcnpr und.r S*rio
<br />U!}AtrEBS:IAMIENSAIION
<br />DECLAIAIIA!
<br />I hcrcby rlilrm ulil]cr PtndltyolFrjuryonc olrhc lnlk,wirg dNlnntrnnN
<br />-lhnvcandwillntri,roiroCcnirKobofConsnrtoScll'lnsur.foreorkers.ompensarioo.!spovidcdtoibyssrbn3T00orrh.tihor Cod., for rh. pcrfo,mRc of lhc work for *hich d. Frftn is nsucd
<br />-lhavcrndwillmoinrlin*orkc6
<br />comFnsalion nFumrcc. !\ rcquircd byScclion -l7m ofrhc liiyn Codd, iorrh. p.iro nm.t.l
<br />lnc $ort lor shich lhisrrmil is nsucd. Mywolkqs c,nlFcnsittrn insu..ncc canicr lnd flnicy nlml,cr !c:
<br />Ehjch lhn pcrnril is isucd.l shlllnor cmpl{,yuypcron in.n! 'nMmr$ rsh hcdrr nlbjcd r,,rhc!1 cr! co'np.nsarion hw\ oI( rlif{nnir. udr3r.rh r if l \hould h.Nrf, shjcd rorhc
<br />$orkcr.on{Fnsrri,,nln,vnionsoiSccrbnlT0Ootrhclf,hnCodc.l\h,ll-fonhwh.on,p!rrirhrhr*ln,visions
<br />WARNINC: l:uilurc h ccurc sor&cr conpcnc(hn cov.rqc is ufhtriul. ind shxll suhFcr rn cn{,loy.r k, rinrinil Ftr,hr\ Md
<br />ciril lincs up ro onc hundrcd rhoD\and dolloF (SlUl,UXr). i!.ddiri.n ro rhc co( otcon,Fnsrrbn. damrlcs as fovidcd ntr rhc
<br />Salion 10?6ollhc l-atn Co<lc. inrcresland alromyi lccs (,ogc4,| s^,6/zt /tf tu c(o \
<br />I IcINSITD coNl'&\(-r(,R
<br />I]III/IAAIION
<br />I h.rby ffinn rndcr pcmlry or Frjury rhar I i li.c {dundcrtr,lisn,norChrprd9(cotrnncmnrSwithScclion7(XXJ)oll)ivi\i{in3
<br />o, rhc llu\ircs\!trJ Pnricsion\ Adc. arxr nrt liccn\c n nr rlllttreudclrccr
<br />@i-lr1
<br />".", 5/4ar11f-,-^** -8.,,'- ?-F. ,I'. < s
<br />raN$f,uql[)NLrNDllili-acENcr
<br />I h.Ehy ntllrd undcr IcnllryolFrjuryrhdt rh.rc h u (n(odbn lcfdin! qctr.y r(tr rh. r.dnnrhNc ofrhc qork lor Ehich rhis pcnnil is
<br />hsucd (s( 1097. civ c.).
<br />I rcnifyrhrr rh0 ,idrrnl rcrrlihons rg,x.lrF rdrnoicnn^rlrrc iorOtrh..hl. r, rlN tr,lc.r
<br />I ccnilyrhnrIh.vcrc rhis rpplic,r ion $]d tutc thrr rh. nh,vc itrrdn ri is.or rd. I r8K In conrlly $irh all Ciry ind Coliry
<br />ordimn.cs trdSr,rcLrs\rcl.li,rBtohuildine.onslru.rion. xr hrrchyauthori2. rcprc*nlarivcs {'flhis Cirylnd Counl} to cotcr upon rhc
<br />rhovc nrtrri('ncd pol)c'ry ftn i'r$ccrion purlioscr
<br />\pplic.nl or,\!rnl Silnalun
<br />H-c,e /(F
<br />*,", </zt/tt
<br />Site-Work
<br />Unde rground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dam pers
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Torqueing
<br />Sub-Panels
<br />Boof To p Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rough)
<br />l\4eter Release
<br />Bough 6-2l"lb :f
<br />FINAL
<br />Notes, Remarks, Etc
<br />Communications Cable
<br />Translormers
<br />Air Conditioners
<br />Vdqfit-'
<br />Service Meter
<br />-LrFc.
<br />-l
<br />ccniiyrh in lhc D.rfornuncc oflhe sork
<br />L€ndn . Ad{nE$:
<br />-
<br />AIEUCANLDICI.AMIIIN
<br />I hodry !,im udcr lcnalry ol p€rFy ot of lhc follo$inB dNlarartuns:
<br />D.mlilion Pcrmik-Asb.{os Noliistion Fc{tcrcl Rceuhl ions (Tnlc 40. Pan6)
<br />-Rcqoircd
<br />Lctlcr of Nolifmtion
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