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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER I}ELCARATION
<br />I hcrcby 0ft1rfl n dcr tcnshy of pcrjury th0r I m.xenrlr fmm rhc ConrreroF Licc.\e lie for rhc rollowine r.,s.n (5$?0315
<br />Busin.s md Prorc$i.n Codcr: Any Cir, or Co! y which rcqtrirc\ a tsnrir !o .on\1fl.I. rlrc. inrrrovc. delmlish i.r rc!.n Jtry
<br />stu.rur.. pr!, k, iis issudn c, aho rcquicsrhc applhmr ror su.hpcnnirb file a sisncd st0tcmnt rlEr ttorsh. k liccnkd'puNu.nr
<br />ro rh. E.visnnh ofrlr Conki.r.r's Liccns.d Law (Chdtr.r 9. Cl,nnkmin8 wnh Sccrio. 1000 of Dilision I of rht Snrincsr a.d
<br />Polcsions Codc) o, th.r lto.sh. ncrcmfl thcrclioorrnd rhe l,.sh lor rhc alkBcd cicdp'ion Any viol,rio.olsdion?011.5$yiny
<br />lpplicanr for a pcrin subjcc( rhc anplicanr b acivi,p.nllryofror d,rcrhan6!c hundrcd dollos (S50Or
<br />l. a\ dsftr .r rh piolrdy. or n1y cnlpkJrrc. Rilh wrecs .s lhcir slc .omNtrsrr ion. *ill do rhc work ud rh. {mru c is mr
<br />i cnd&l oroficrcd ror srlc (Sr.?(}1,4. Busincss.nd ProfcsionsCodc rhc Co Ectn s l,i..n{ lju docs nor nppl} lo 0n owmr of
<br />rhcnmpcny sho builds or impn,lcs rh.R,i, mJ qho d,$r!.h $lnk hinsclfor hur\clfnr rhrongh hn o! h.r owncmpk,ycs.
<br />provilcd rhi! \uch inDmwnrnt trc m! inrcndcd o.olhErl lir ek ll- hoscrL rh. hlildin8 or iq'm€Enr h \oki wirhin mF
<br />.lonryLli('n- rlE ow.cr Auills sil nrvc rrE l,urd.n ol poinc rh.ll hc or \he diJ 'x, huild or i'npmrc 6. pmFnt for rlr puqncof
<br />,l. r\owrcrofthclrotcny. rtr,cxclurivclyconrrrcrins with liccnscd coirrscttr* k, L{n{flcr rh. pn'jet (Scc 704,+. Brsincs
<br />dnd lhf..sb Codc 'I'h. C.nrdoi s Licdn\. Ltrw docr n.r afirly ro un .qncr of l)lollcny who builds or imrrovcs rhdco..
<br />lad who onrBcis for suchrmjcG$n!a conrEcro(I lt cncd plnua brhcc(,nta.roas Li.cns! Ijs).
<br />-l
<br />amcrempr lndcr sccrn,
<br />lll)atrEtssiaufENlafx)N
<br />DICI,I.8AIIAN
<br />I h.rc$yainflnu dcrpclalryolpcrjrrtnicofrhdtuln,wii'sd.ch,rridN:
<br />-lhovcandrillmirlli.aCcnificarcorConscnrroSclllnslrcro.workcsonF.s.lion,asprcvidcdforbySedionl?(Dorrh.tibor Codc. for thc l).norm0mc ol lh€ uolt for which thc pcrmir n h\td
<br />-l holc and will m0inrain sorkcF comFnsarion inruoncc. a. rcqrircd by sd n l?00oflhc L.bor Codc. tor rtr tdfomukt ol
<br />rhr w.rtffl *hich,hNnsm ir i@ M ) w.' k.' y ft,nrc1sri"n in\u' 3nc. crn.r un n lic) nu mbs Ec
<br />s+4, j1^-
<br />dLt*,r^,, 6-t l,
<br />I ccnily rl in rhct rrontutr.cofrlr w.rk forwhi.hrhi\ p.nnil i\ i$ucd.l slnllnolcnnk,yar, tr6.tr ir rnyntrn.cr
<br />$ N ll, b.conE nrhid t(, rlE wortcr .unDcn (ion htr \ ol Cllii,,ni .,n tr!tu. rh irl sh.uld hc.onE sunjd ro rl'a
<br />Mrker\.onrcn\di()ntrovi\ionsofSccrii,n.lTfi)otrhcliln(ixlc.l\hrll.f,)nhsirh!.mplysilhrho\cDmvi\ion\
<br />WARNINC: a{ilurc ro scurc Norkcr'conpcns,rn,n corcnsc is tilawrxl. Md sh,ll \uhicr trr cnlllo}q ro ridnllp.hrlrh\ nnd
<br />rivil fims up ro orc huMrcd ihousand dollar (Slfi,.fixjr. in oddiri.i ro rh. .oj ol $nlPcnsttun. darmacs a\ Polid.d r(n rh.
<br />sNl ion :1076 oi lhc Ljtsr Codc. inrcrcsl and lrrormyi iccr
<br />?-to-tg rrppricmr: U.'-
<br />LICINIEDI;ONIBACIAA
<br />t,FCI,ANATIoN
<br />I heEbynifirmundq Fmlry ol pcrjor, rh!, I anlidnsd trndcrpblisio. ( ch0pld I (m.nnrEina *ilh Scc! krn 7Ux)) or Divisi .l
<br />of lh. Busim$ and Pn,lc$ions (ndc- and nry li.cn\c is in lirl li,c 3.d cr.cr
<br />(-co IarVAt?
<br />c-( \(-v
<br />CANEISULITONIINIINGNCENT
<br />I h.Eby aflirm undd Fnrlryorp.rjuryrhd lhcrc i\ a .on{n.lion ,.rdins rScncy li'r rh. Ilcrfnnlan.. olrhc work lot lhich r[n Frnril is
<br />i$ucd lscc.3097. Civ. C )
<br />AXEUCANLD&CI.Af,AIION
<br />t hcrcty afm undcr rEnrlry ot p.rjuiy om .f rhc lolLwing d..la.rr ions:
<br />Demlirion PcrmilsAsb.sos Nolific.rion l'edcml Rqllolions (1 ilt 40- Pan6)
<br />-Rcquncd
<br />Lllerof 1L, ilicalion
<br />l.cniryrhrrhcrcd.tulrrBtrlrri(,\rc!ddir!1!h.{osrcN,vilrNtr.l fplic'hlchrhnInlrcr
<br />-l
<br />ccrlityrhd I novc rcldrhn rpflicart'nnnd dardh(rlEltnt intnmdn{ i(.oftc.' l.!tel.mnliywilhaUCirynndc{rnry
<br />o,niniNcs nnd Stalc Lsws rcl,lins lo huildins conndcrn,n. afrl hcrcby rurhtri2. rcprcs.tr'rtircs ofrhh Cirynnd Co,nr, k, chrcr upon thc
<br />lh|v. nrnltrnrJln,JYnt l.l fi.*..\2'?L
<br />{pprrMnror As.nrsrsmrun A:J j7 J
<br />Pemh*Ehe,pr,nf): /a"'L t':
<br />1--( t-rk
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFEB
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Rouqh
<br />Ceilinqs (T-Bar Rouoh)
<br />lrleter Release
<br />Rouqh
<br />Service lrleter
<br />FINAL lolp ltgl 7>rryqzco /1zz)
<br />Notes, Remarks, Etc.I ot
<br />Air Conditioners
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