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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDEN DELCARATION
<br />I hcEhy silirn unncr pcn0hy oi pcdur, rhat I am excmrr 6onr rhc (bnrrucrqi l-iccnsc Llw for rhc aollosing rc.$n lse.7oll.s
<br />Alsinc$ and Pronssion Gxjcf Aiy Ciry or Coury qhich rcquircs 3 Frnir ro con{flcl. nlrr, imPmvc, dcmlth or rcPlt my
<br />slrudur.. pnor ro n\ hsudft, als cquncsrhc amlic,nr ror su.hFmnr to filco sisncd slolcmnt rfilr heorsh. t liftn\ed flrn'anr
<br />ro rhe lr'olisions olrlE Conrocrors l-iccnsed ti{ (Chlprcr 9. Comftrcing wirb sc.rion 7000 of Divilion I ollhc ausinc$ 8trd
<br />Prcfc$ions Codc ) or rh.r hco.sh.,scrcmfl lh.r.fromand rh. b*is for lhc duc8cdcrcmtlion Anylidork'nofSc.lionT0ll 5 hy itry
<br />apllicaDr l'or I p€,ni subj(ls rhc applicnnr ro acivilpcnllryolnor {rc rhln fivc hondftd ddll&r($50tr.
<br />l. ns owncr or Ihc proFdr. or trry cnrplolccs qnh s,Bcs as rhcir sh co$Fnsal ion. will do rhc worlr a.d rlt d im is nor
<br />inlcdd or otfcrcd fm slc (Ss 7044- Businc$ and Pmicssions Codc 'rhc Conr!ac'r,\ l.kcn* tjw ddi tu' apply lo !n owE ol
<br />lh.poFnyqhobuildrorinFoltsih.id,(,nlwhod@!.hftihnnscltoitur{lforrhrou8hhhornrowncmplorccs.
<br />phlid.d rhar su.h imptuhmnls e n.r int.ndd or ofirrd ftn ekr. ll h,wcvc., rtE btrirling nr irtrorrmfll is $ld wirhid oN ytd
<br />ol of{Ltbn. tlr Ownd Build.r ,ill lEv. rhc hordcn .f proving rlxd hc or \hc did nor hniE or impbw ih. toFny f.r rh. nu{rs of
<br />I. N .*mr of rhc |)ft)lrny. {n cx.fusncly coffa.rin8 wi'h liccnscd conrrrd.r\ ro con(rucr rhc rrujccr (s* 71x4. 3u!rc$
<br />!d hna$i,n Codc rhcConhcroisLiccnscl,owdocsnoronDlylortrowtr.!ofp(,penywhobuildsorinDmvcsrhercon.aid sho @nracr\ tf soch pnrjR( *irh. conrack,(n licenscdpur\u r krrhcconrrn ktr s Lic.nsc ti*)
<br />lrmcxcnrfl uDdcr Sccl
<br />Oener:
<br />roarE&Ll:outliNsaugN
<br />DEslrtS[floN
<br />I hcr.lry rfiflnundcr pcnnlly oa pcrjur! orc .i lhc ,ol1.wir8 dNlrarion(
<br />-l
<br />hatt &rl s ill minrrin a ccnific.rc of co.scnr ro sclf-lnsurc ror worlcr'compctrsalion.as nmvidcd ior hyS.crid.lT(x) ofrhc
<br />khr Codc. rorth. p.rfomDrcc ofIh. q lor whi.h lhc p.mir ishsucd.
<br />_lhoveand will mainlain workcB comp..!trrion insurskc. ar equird by serion 1700 orthc rjhor Codc.Ior rhc pcrlomoncc oa
<br />lhe *ort a.r whichrhispemil is is$cd.lly worke^ d,mpcns,rt,n inrurmc .,ri$ dld ,rlicy nun$cr m:
<br />c""t",, - TLO
<br />)c-OC dl?.a/t9I
<br />-_l ccniti lhr ir lhc pcnonmncc ofrh. work fi,r whth rhi\ p.rn,ir is ksu.d. I rholl tror cmfloy rtry t,cHon in lny manncr
<br />ciistub.coirsubjc.rrorhcwo*cn.omp.trs.rmnl.*sorcr,litunria..n lge lhal itI should bcom subied kJ rh.
<br />workcN co'nl)cnrariotr ,rovisions olSccrion:l7u)ofrhc lntn Codc.lstEll- r'onnwirh conpl, qirh rhos F,vtions.
<br />TVARNING: Faihrc ro scurc *ortc onEtrsatn'n (!crr!c i\ unh$iul. rnd shrll luhjccr m cnrpkrrcr ro ai'nitur p.iJri.\ dnd
<br />.ivit rincs up h onc hund.cd lhournnd doll6lsl$.ujo). h rddni(r ro rhc cosr ofc.npcnsrrin- dn.E8.3 0s lr.vidcd tu rhc
<br />S.rri( :1076orrhc Latrtr C-( .. ir crcr rnrl rrrry'!li.\
<br />D...,:LftLLtg apPriunr: )1i
<br />, hcrchy rlfirm und.r Fnrhyofp.rjry rhd Lm licctrr{ uM& f'ovhionofCluprcr I (.o'nmncing sirh Sccrion ?O(X}) ofDilision l
<br />of rhc Arsinc\srnd Pbfcrsn,nsCodc. ad nrylk.n* is in full ,nr.c ,rd clfc.rP a
<br />C(t?ltY a
<br />ATILEANI.DECLAEAIION
<br />I ho$, ammudcr Fnalry .r pcrjury .ft of rh. rolk,{in8 d*llnrrions:
<br />Dcnnn iotr PcnnnlAstEslos Notificllio! Fedc8l Resubrions lTnE.r0. Pan6)
<br />-Rcqoircd
<br />l,rrcr of Norir&:ri.i
<br />aa [.ldT! thot rhc lcdcralrcpuhnnns rcsa'lrnq !.tr$o\rcmrulr,. B{ 3rrprrJble rorhi'pmj.rtwf-
<br />Ilcdrb rhxrI hu vc rcdd rhnannlicrr'onrld c rhr hc dhovc inlirndion G .otrcl I oEN ro ohply wifi all Cir, and County
<br />ordinancc! and Srarc L€*r relarilr8 ro buildin8 condncrn,n htrizc rcFcsenhrir.s oilhis Ciry aDd Codnryro cnrcr urr{ rhc
<br />ab.vc rrnhomd pop.ny lor insldiotr purpossr,,
<br />,rppri.,", ". ,r*"n, Si*nr. *, )(_
<br />Pemil.e nnmerpnni)r Y_I 2tlar lrtN ldt c!+!3
<br />Underground
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Lite Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab i Floor
<br />Bondino / Groundino / UFER 4)
<br />Transformers (/l
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Solfit Rouqh
<br />Ceilings (T-Bar Rough)
<br />[/eter Release t ..<--\
<br />Jv-eletxou^,1 l1dj.^J1 v *14 v
<br />.!r2'
<br />Rough J rp slt$\i.2r)-
<br />Service [/eter t4 fr-)
<br />FINAL 7")
<br />Notes Remarks Etc
<br />Site-Work
<br />a
<br />zi1 )t a :n It IIJNjiIaIjCIIONIINDIN(;.AGENST
<br />I hctuby dffirfr undd pcndhy.r r.rjury th,l lhnc is a consru.rion Lndi.g oBcncy for rhc pdtoirucc of rhc wor* for which rhis Frmil h
<br />hsucd (Sec.109?. Civ. C.).
<br />tr'trJci. Nrnr
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