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EL RICAL.INSPECTOR RECORD
<br />APPHOVALS DATE COMMENTSID/SIG.
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountarns
<br />Siqns (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER t ),nfc loz
<br />Transformers
<br />Torqueino t lo llI fi.c b't
<br />Sub-Panels
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilinqs (T-Bar Rouqh)
<br />lt/eter Release bhol rc fst* k)1
<br />Rough
<br />Service firleter 4 9l,ttd 1.,3
<br />FINAL C lro I r9 Cl b\
<br />Notes, Remarks Etc.1
<br />rYrrrf.J,^t D*rr..
<br />I I
<br />\/r"r-Upha^. -2^\
<br />Y -\-''t , \)
<br />OWNER AUILDUR DELCARATION
<br />I krcby affirfr undd F..alry or tujury rhar L'n crcmpr fb'n rhc Conlra.roN Liccns. Law for rhc follosins r.rv,n rsc. Toil :
<br />Busi,rcss a.d Phf.sion Codc) ny Cil, or County which rcluncs a [En.il k' .oidtucr- olr(, inpbvc, dcnml$ .r ePan My'
<br />$rudurc, rio! to irs issu!rcc. also rcquirc\ rhe lpplicmr ttr such Fnnir ro filcd \ign.d sarcnrm rhd h.or shc h liccoscd lurstrnr .
<br />ro thc tmvnn,ns or lhc 6nrmclors Liccnsd bw (Chlptcr 9, Connncncins qilh Sccrnnr ?O{D of Divhion .l or rhc Busnrs\ .nd
<br />Pn,Icssn,s Gdc) or thar tE or stu kcr. lprrhercfto stul rhc basi\ tu'rhc trllcgcd cx.m/ion. Anyliohrionofs(lionT0.ll5hytrny'
<br />rrflicanr ror rpcnnn suhjen rhc aFllicrtrr to.civil pcnahyofnol nstc rhnn iivc tundEd doll6 ($500)
<br />_l- ar oencr oi rhc pmpcn y, ,r my cmpk,y.es wirh *a$r n\ rh.n s,k L$m|].nsarion. will do lh. work rnd lhc n nde i\ ior
<br />inrcnlcd or ofr.rcd for {L (Sft 1014. Busincsc md Pr.fcsn.ns Cdlc: Tlc Conr0clois Lietrsc L!* d€s ml alpl, to r. owtr( of
<br />rhc l)R)pcny wtu brilds or imnl)B rhcmn. a,n who des se-h q!* hinNcllor hc6clfor rhn,ugh bi\.r h.r own cnfhyc.s.
<br />pn,vnl(l rhar such inrprn*nEnrs c mr inrcnd.i or oLcRi fq elc lU h,kk,, rtr h! ilti.g or iflpnrRnrnr k sld wirhin.m ]qtr
<br />ol'complcrion. rh.Opncr lhildq uillhnvc rhe i rdciofpnvinsrhd h.orsir dil mr t tlo, i',{m!c rh. pDFiy rbr rh.,u4nkor
<br />_1. rs.wmrofrhe pnDrnr. nncr.lxsikly.unrrcring *irh li..nfd cDnrraclon to ronstrucrrhc lro]ccr(se 7044. Burinc$
<br />ond PtolLasbn Codc: l hc Co.lracrofs Liccnsc Law d€s nor lptly ro otr owncr olpropeny *ho huild\.r inprorcs ihcr.on.
<br />and *ho d,nrrucls fn slch pr+c( sirh { Cod@cx,(, liccn\cd purenr ro rh. c.trktr ttr\ Lk.nr tjw)
<br />Ianr.rc,flundcrSNii( .4 &PC li,.rhi\rcaron
<br />Dol.: Ownei
<br />woRt(ERs coMPflls 1!()N
<br />DECLAM]IO!
<br />I htrchy altum undcr pcMlryoiFrrtrryoic oirhc lollosin8 dalaralt,nq:
<br />-llrvcsn{illnEinroinrCcnilrdrcofConsnrroScliltrsurclbr*orlcd..nvcnsarbn..spmvidcdfubySccln,nS?00.llhcLln)r Codc, ior lh. pdloflIft. of rhc work lor qhicn lhc ,cmil is ksucd.
<br />_l haE rnd willMinkin ru[c!! .on]Ftr\ar i(h in\urakc. i\ rquncd hySo.riotr:l?U)ol rhc tibor(odc.lorrhc pc o.nnn.cof
<br />rhc *ork i{n *hich rhhlEnnir is is\ucd Mrworkcrr comp.nstiin in{trancc .ari$ dd NIi.y nnnlbcr trc:c*t ?+(Tt? aiw1.
<br />""""""
<br />l."niryrh,t i.ihcFh,**., rh. w.rk r.. sh'.hrhnr."n rtrru.d.I.h0lltrorcmlln)rnyncr..nrtrnym n,
<br />sasroh&!msubirrrorhcsorke$com!.ns$nrnhwsofcililorni!-$drsNrhdiflikiuldhecom{bjeclb'hc./
<br />uoricrs' comp.ns ion pmvnions oI Sdion 3?00 of thc Llbor Codc. I shall- rodnwnh cotPly wi'h rho$ Frvhions
<br />S.criin,.rl)76olrl,c lrfitr Cixt., i' crc( dd rnonry \
<br />;f^*.,.,";X4d r+rzlaA h^
<br />DECIdBAI]O!
<br />I hcrcbylffirm undcr lEn,hyofpcqury lhll I am lienxn undcr J,mvisn,n ofChrpru 9 (.ommncnrC wilh Sdion ?000) olDilhion l
<br />or rI1c Busincs mJ Pofcssbns Codc, ard rny liccn{ is in full lora nd cl'lar
<br />b*'$aqar4t d ,J e awgirr+n{,
<br />I icrchy slltmufftq p.nllrrof!.rjury rhd rhm h a..n$tu.rion lcMing d8cmy for lhc pcrformamc oflic *ork aff whkh rhis r.mir is
<br />tsucd (Se.1097, Civ C.)
<br />AITLIIANI.DECIAAAIION
<br />I1m.1,, animrndcr pcna!ry ofpdjury un ofrh. folbwint dNlrarnns:
<br />DcnDlirnnr Pcrn rs Asbc{os Norilictrri(,n Fcdcrdl Rcguhti{Jn\ (Tnh 40. Pd6)
<br />-Rcqnncd
<br />Gtrcr ol NolifElrion
<br />_ lrsrifyrl,ar I hav. r.rn rhis,'ntli(rri(m nd {nrc rhxrrhcrh,r rf,n [r n is.orccl I ngre h.onply sirh nll cityntrd ( otrnly
<br />o',li',rD.cl rtr,lSrrrc l.rs\ rchring n' huil,litr!..nn \c irnc\.1'lhn Cny 3nd A,unry t, o r(uI! rlt
<br />abovc nrnrioned pm0cny for insocdionl)u
<br />'\pDlir nl or,\sr.l Si!Dnrurr ho ft
<br />,"'"$ra1r{:or/
<br />Air Conditioners
<br />lo
<br />If,nJ.ir Addrfl(
<br />-
<br />_l ccnity thar rhc {cdcral rcExlarnrns Eldding ish.s.sfum)vrlftc no',a'dErblc to lhh pmrccr
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