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ELECTRICAL.INSPECTOR BECORD
<br />APPBOVALS ID/SIG COMMENTS OllNIIR BUILDER DELCARATION
<br />I h.!ch, affi.i u.d( Fn,hy .l pcrjury lhnl I !m cxcmpl fmrn lhc ConrrriqJ t-i..ns. Lrw lor lhc lollowiry rcason (ss.70.11.5
<br />Bu\iness md Piorc\sion Codc): Any City or Counly *hich rcqutcs , l,.rnil to .oDstrud. alrct. improv€. d. lnhh or ruprir my
<br />iru.rur..,,rior ro ns issue..c. d\o rcqunFlhc crplicsnl lnr cuch Frni' h filcn siBRd stnlcmnr rhal heor sh. i\ li.cnEd pusuatrl
<br />t, rhc pmliri.n\ ofrh. Contr,.ror\ Liccncd Llw (Chnllcr 9. Commcncin! sirh sc.rion Tom of Oivision I ol lhc Auqn'.n and
<br />Ptur.\qions Cod.) or lhar h. or snc n crcmfl rhcrcfrom lnd rhc l,lsis rnr rh.,lLecd cxcmplrn. AnyviolalionorSd'hn70ll5byrny
<br />orpliclnl fo, r pcrmir suhjell rhc dtpli.dr k r civil Pcnrhydl nor nxrE rh lire hundrcd dolh. (S5tr).
<br />l, rs oqncr olrhc popcny. or mrctrrpldy.c\ wirh wi!.s as rhcn sob.onlpcD\olion. $illdo rlE sffk nftl rhj {muN is mr
<br />idcndct or olltrcd f{tr {k I Sd 7(x,1. Businc$ ind Profc$ion\ Cklc Thc Conkrroi 1 Li.cns trs docs nol lpnly x' !n owmt of
<br />rhc pRIrny wtrJ t{ilds or impr.rcs rh.r6o. arxl *h. dms skh ${,:1 hinsclt oi hcrsll or rhnuSh his or hcr own . rlrhyccs.
<br />pmvidcd rhar such impturn.nr\rNnor ii cndcd oloffcrs.t for $k.ll howcv.r, rhc huikliB or n\rNtnE r$ll wirhinonc }tr
<br />oiconDLrion. rfu Owner Bxiklcr willhavc rhc hudcn ofpmvin8 thar hc or shc did nor huild or inPmR thc pmFny lor lhc puqns oi
<br />L r\osncr orrhc pn,pcny. rmcr.lusivclyconfu.(ioa wirh licc.scn conrmcro^ ro conntu.r th ptulccl {Scc. ?(}+r- Busincs
<br />$d PFllishn Codr:'rhc Conrracktr s Litcnsc l-iw docs nor !nFl) ro m ownct oaproFnt eh(, builds ot inrProres rhcrc.n.
<br />anJ qho .onrrn tsforsuch t)mjccrs wirhaCo Ecntr(,licciscd puau,r hlhcConlm.ror's t-iccns.lis)
<br />I ahcrc fl und& S..rio
<br />]}QBtrIBLCOIIIENS,AIIOX
<br />I]III.ATA.IION
<br />! hcrchy trfiilnr r er Fnalry .r Nrjury onc ol rhc njllo*ir8 dslnr ionr
<br />-l
<br />havc and will minrd. a c.nificdrc .r coned ro Sclfinsue fr work(i conrcnsarion. rs l,6vidcd lor by Sart,n l7(xl orrhc
<br />ljhor Code, nr rhc pcrfomnce.f rh. work f(r uhi.h rhc Frnrir ( issued
<br />I hrvcrnd will nrinuh workcrl conrpcn$li, irnruncc. !s rcq ncd hySc.ri, l70(J ol lhc lrl'orCode. tur rh. Frfonrumc ol
<br />nr \rrkntr \lrihrlr'\lrnnI i\ i\n]c,l ltl uorkcn compcn\art,n i'r\urunc. .rfti$ dt policynumh.r arc
<br />'I {t firr 3/zz/r(44ut C-Qln?
<br />-l.enify
<br />rhrr inrhc pcrfo.mrc orrh.work r.r whichrhi\ p.rmil k hsucd.l shdl nor.mtloy a.r rcson in lnynunmr
<br />$ as ro bcc.'ft *ubjcr (o {h. $o.kcK or.pcnsrion laws oacrlitomia,,od e8ft. rhd ill should tEom sur,}rr ro (tr
<br />trork.^.orp.N{nrnpnvisionsoiScclion.lT0{)olrhchtrOde.lshalL.fonhqi(hco
<br />W RNIN(;: Iirilurc t, k.ui. qorkcF com|Etrs lon coErrgc i( unh*ful, trd n cnuloyc! i, dininil l.trrllir and
<br />.ivil fifcs uf i) onc hrndrcd rhousanl dolllr! l1llx)Ux)). i]r rti,liri{in soii.n. dam3es r pRrvidcd ft, lhc
<br />:;:::TfrI ir crc{ nM ! onrv slcc\
<br />t nro,.*,, 14
<br />I horhyrlitru dcr t).trillyol t{rtr'yrhnr I rn,I'r.n*lutrdo tro\^( r I(.o'nnrn(i',8 r h Sc.rii T(Xx)).il)nnii,nI
<br />ol rhc Bnsircs\ arl Pmlis\nrN Codc. lNl trryli.rn* i\ i', n,ll turcr
<br />B .l)ZtofuZ
<br />.^**",ytte @4ct9 Cru, (Muchtt
<br />I.:ONEIISEIONIENDINCAGENII
<br />I hcrchyafinnrndcr p.n,lrt ol p.rjury rhal rhcrc n a con(rucrion lcnnirs,ccncy ror lhc rcrl'orrorcc oflhc work li,r *hkh rhis lsmt k
<br />i$ucn lscc. :1097. Civ C )
<br />A.PILISANLDECITIMIa!
<br />I hor{,y.Rim hdcr pcnalry oa pcrju, oft otrh. rollowinS de.lraliotrs:
<br />Dcnrlilion Pcrnih'Asbcslos Norilicarn,n Rdcrdl Rcgulalions (Tirlc,l0. P0n6J
<br />Rcquircd t rt rolNorificdion
<br />lcn lirln' rln rcd.rrlrrrtrlxrotrtngrJrtr!r\lt{o\rcNrnlrrc
<br />,5 .cniryrhd I have rcnd thi! lP!li.dion0rkl sral.thoi thcotnvc is.tr ccl.Iaffe ro.omnly {irh rllCiryand C.utrry
<br />tnr.{ntlrivcs oilhh Ciry and Coonry ro cnrd trrsn rhcrmc\n l Surc Uqsahrirsto buildingc.n\truclioo, l
<br />rtx)lc,m n)md pft,t dyfor irs|r.riotr puryroscl.
<br />AflliixnlorlA lSixn!ltrrr
<br />u"-,,*.,-",u,*,.)(. Nqt^-Z
<br />qft/ls
<br />Sile-Work
<br />Underground
<br />Pole Bases
<br />Lioht Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondinq / Groundino / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Solfit Rouqh
<br />Ceilinqs (T-Bar Rouqh)
<br />[/eter Release
<br />Rough 1kl4 1/lolrc 5'b.'6
<br />Service NIdter
<br />FINAL 1/ ts //v 90) fi
<br />Notes, Remarks, Etc.
<br />-+
<br />DATE
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