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ELECTRICAL-INSPECTOR RECORD
<br />OWNF]R BUIT,DER DET,(ARATIoN
<br />I hcrcby olllfln undcr pcnohy ol Frjury rhlr I dn.x.mfl rn,n rh. C.nt,crrtrs Li..n* l-aw r(tr ttc f6lb*ing rc,soo (S.c.70.11.5
<br />Ausincs rnd Profcsion C.dc): A.y Ciry or Counly shich rcquncs a ncrn lo .onnrud. iltn. inrFrvc. dcnxri$ .r rcNt any
<br />ntucturc. prio lo its isuarcc. ako mquncs lhe 0rpli.n r ror.u.h l)Cnnir t, fiL, si8kd nsrc.Eii lhli heor shc h liccn\cd plNuant
<br />to thc ltovisions of rh. Conrr.x, s l,i.encd Lrw lchaplcr 9, Commrcir8 *ilh Scciio. 70U) of Divnion I oflh- susncss.nd
<br />Prcicssiotrs codc) or thalhc or shc is cxcnfl rh.rcfmm and rhc bask for rhc allcscd excnq,rion. AnyviolationofScdi.,n?03l.56yrny
<br />aff,licanl lbr a pcn.il subjcck rnc appli.anr b d.ivilpcnalryolnol morc rhun fivc nundrcd dollars ($500)
<br />I. ds owncr of ltc pmp.ny. or my cm0lolccs wnh wi8.s as $.n sb .onD.n\d bn. uill & rhi w u41!h. iturm6 nor
<br />idcfldcd or offcrcd ror srlc (sd 7(I,14. Bxsincss and Proic$tnN C.!cr'flrc Conl,aclols Li.cnsc tjw docs nol optlyto 0nowrcr ol
<br />rhc Ptup.ny who hrilds or impmws rtEEo. atlll *ho des sh m* hnnsclror hfislfor rhoueh hn or h.r .en c'lrl)loyu.r.
<br />providcd rhlr such imamEnm e nor i, cnd.d or dfiurd tor {lc. lL hosds, rh. hdilding or iq,roknur i\ wH wirh'n om tu
<br />ofonrplclion. thc orncr Builda will h,vc rh. burd.n oI ptrNiry rh,t hc or shc dil trorttrild or iflr,,&w c ttupiy for ttr NrrFs o,
<br />l. rsowncroirh.protirdy. rtrlcxclusivclr.otrhrcri !*nhliccn{dco rsclns n, (n,(rucrhc nrc}cci (Scc 1014. Bu{nus
<br />a huf.sstunCodc: Thc Contrktr s Liccnsc l-rr doc\ nor anDly ro un o*ncr olF)!.ny sho hxrlds or nnlroves rhcrotr.
<br />and who conracls Inr such rmjLrh wiih r C.nhd.rd s) lrci\cd prr\unr b rhc C(,nrrcrtr \ t-ienr L$)
<br />-I
<br />an*cmpt undcr Sdio
<br />UAAtrE&II:OITTDNIAIIAN
<br />IECITIXAIIQN
<br />I hcEh, amrm under pcnalr, otr.rjuryom olrhc folk,wing dcclrarn'ns:
<br />I h,!e and *ill minrain a Ccnifiore of Coa*nr ro scll-ln\urc ntr worrqt ..mp.ngr io., ,i rmlid.d lor b, sBl i{'n 3700 dt rh.
<br />Ln6or Codc. for rhc pcrfonmmc ofrhc m* ror whi.h rhc p.,nn n h\!cd
<br />x hav. .nd rill hainiaiD *orkcF comp€ns.r ion inuronce. N rcqnncd h, Ser ion :17{x) of thc Ltrb(, Cd.. fttr rhc pcrfdmtuc nl
<br />*ort lorwhi.hthh p.mir is nskd My *o,kc( coflrpcneriotr insuEtrcc cinicr oxl Flicy.umbc. dc
<br />s l.t/c \-t)633 )rt
<br />I c.nirr rhal io rhc pcrlbrnun.c ofth. work ln qhi.h rhis lcnnn is issudd. I shsll n.r cnl,br r6y r.rv,n in rny manft,
<br />b es to tr.oN subjer io rh€ w.rk.. co.rF.qrt'n luwsolcalinxntu, and 08Ec thd irl shruld bcconr su6jcd tu rlE
<br />sork 6 onlpcnerionF,visions ofSsiion l7(x,olrhc L.bor ( ftIc. I shall. ..n h*ilh on{,ly qirh rhos nmvisions
<br />WARNh'C: t;ilurc ki r.urc sorkc^ onrp(n\rrion.omrr8c i\ trtrlr*lnl. nnJ rhrll \ub !n cmployc, ro qininll pcmlrics otrd
<br />civil finc\ up ro onc hutrd rhousnrd dollh (!100,(xrD, in ion- nJ Hg.\ r! lnivid.d I{, rhc
<br />Dar. €I
<br />I hcfthy rmrhundcr ncnalryorri.rjury lhal I am lieost uodcr povkion olChopts 9 (<,nmn.ing enh Sccrian 7m0) ofDivnion l
<br />ot rhc Ausincs ond Profc$ions Codc. rnd nry li..ns h in tullrndiddcrlcr
<br />ac)^y o6 )?
<br />ryv
<br />I hcrcby afitrnr undcr pc.rhyofpcrjxry lh,r rhcrc is s consrtuclion lcndins aEcncy i(tr th. p.rlormuncc olthc *ork tu whhh rhis pcrmir h
<br />issu.d (Sr..l097.Civ C.). t
<br />AtzugtNLOliqLA.EAlAN
<br />I h.rchy diian undcr Fnally orl.rjuiy onc ofrhc rolloeirs dcclarotions
<br />Dcmolirion Perons Ashcsros Nolificalion trdcral RCEUhrions (Tnlc 41. PdO
<br />Rquircd htrcr of Norifi .arir.
<br />-l.cni!thd
<br />rlt.i.dcnlrc8u]driuis rcIddilg ar]r{o\ rrnmvrl rc trol fplicrhlc i' rhtF!.rr
<br />(..niryrhd r havc lcad rhisaprrka
<br />ordiMtrc.\ di srar. titr\ rchinE h
<br />rhovr ncnri,nrd pn,pcny i,r iI
<br />,\ppli(!nlorAgcnl Sigmture
<br />DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safe ty /Low Volta
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / 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 />Ceilings (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rouqh)
<br />[/]eter Release
<br />Rough
<br />n
<br />FINAL E-rt-tv [.tLd0
<br />Ngtes, Rem arks, E(c
<br />C4^/
<br />I
<br />i(nr is.orrc.t I ngL! r' (onrdy sir[,ll cry iM cntrnly
<br />n,,","r,"t"tr^rt"..tt,r")_rr",r"[fi
<br />;;;r*^*
<br />APPROVALS
<br />Service ltileter
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