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ELECTRICAL-INSPECTOH RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundino / UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Condrtioners
<br />Bool Top Equipment
<br />F actory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Rouoh
<br />Ce ilings (T-Bar Rough)
<br />Meter Release
<br />R ough
<br />Service It/eter
<br />FINAL 9lt t11g ,,ua(tc )
<br />Notes, Remarks , Etc.
<br />OWNER BUILDER DELCANATl(,,N
<br />I hcrchy umrm undcr pcnllry()fEj!r, rhat I !m cxcnDl fm lhc Co rucloN Lk.nsc Llp for thc {ollowins rclstr {scc70.11.5
<br />Bu\incs ,il Pmfcsio. Cdc): Any Cny .r Counry which rcquircs a pcnni' k, con{flc', aho, inpnJ!.. &nmlkh .r rFn M,
<br />slrudur., t ior lo irs hsuamc. rlso rcqlircs rhc lpplicMl ld suchr.nhil to ilcs siSncd slalc,mnt rhtrl hcorshc h lienscd lururnr
<br />lo thi prurision* ofrhc Contakn s Lic.nsdl taw (Chapr6 9. Cohftking *irh S.crn,n 70fi).f Dirkion I ol th. BusincN od
<br />I'mfcssions Cod.) or thar tE or shc k cxcnpl lh.rofrom and rhc b.sis for thc trllcBcd cxctrrplion An, violaliono{SccrionT0:ll5 hyan,
<br />rrpli.anl l'or a I'cmil subjals rhc at,plicanl toacivilpenahyofnol nrrc than firc hlndrd dolh6 (S5U))
<br />I. * o*ncr ol rh. nmFny, or my .nlplortcs wirh wdg.l d{ rh.n htu co.rtxrsrnor. sill d. rhc wtrk rd rh. imtua i\ ml
<br />i c.dcd oroficrcdforarlc(SaT0l4.BusincsandPmf.sionrC.dcThcCnnra.rorsLiccn\ctrwdocsnorq'!lyro!nowmr.f
<br />rh.ptuIfny wlm buildso! in!}mc rhcB)n, unr who &Es sch slt hnnsclfor ncrclfor lhrcu3n his or hq oNn crpl.yrc\.
<br />Drovilcd rh0r su.h inln)vcmms N mt imcMcd oroficrud fqsah.lf- ho*dci rhc brildin8 orimpmee'ftnr isq,H snhinon. rrtr
<br />olcomddi)n.rtrO*ndBuiLLrsillhrycrhchurdcnolprovingrhdlEor\hcdiltrorhuildori'I0rovclicloFnylarrhcpqnsof
<br />l. o$rc.ofrhe rroFny. mcxcluriwl) conhclin-q enh li.ctrscd conrrocroslo Nn{rucr rh. pn,jlrr lScc.7(N-:r, Busii'c\\
<br />nul PiDfssir C.J. ThcConra.roasLi..nscLr*doc\noratpltt,rno*n$ofri{)prdywhol,xililsorinrtovcsrhcrcon.
<br />and *ho conlr.ch n, such prcjccls wnh ! Contr.don O li.etr*d runumt ro rhc ( onricrois Ltcosc ljw).
<br />-l
<br />am cxcmol utrdc, S(lion-. lt & P.C. for rhis rcu$n
<br />UOBKI&1j:OIIIENSAIION
<br />Dti.ct xtrua!
<br />I hcrchy !finn undcr r.nalry ol p{riuly.rc or'rhc Inlhq'ins dcclararions
<br />-lhavcuxluill,mn
<br />nin a Ccn iaFarc oi Conrc roS.l trsu.c lor workcN .onFnsation, !s pmrid.n ror byScclnrD ITOO ofrhe
<br />tibor Codc. ror lh. !.rrdmc ol lh. work ror ehth rh. l.rin i{ hsucd
<br />_l h{!c atrd willflrBi oin workcr' conFensBlion insunrcc,.r rcquircd hySaliru:1700olthc l,ahtr Codc. ti,rrhcr$ro'.'tric.or
<br />lhe work lq which this pe,nrir is hsu.t MyworkcN comNns,lion insuroncc clricr ann rnicy nunrhrr m:
<br />l.cdity thrr i. thd lcrformtr.c ofrh. *ork fff *hich rhi\ I.nnir is ksucd.l shall tror.nploy rny pcron in lny m.nrcr
<br />s m ro hc.onr sunid h lhc snrkcn'conlp.Dsol ion laws of cnlirornin, ond laEc Ind il I sholld bccom subtd ro rhc
<br />so*cA' compcn$tion pmvhions of Scclion 37I[ of lhc tjtn Codc. I stu]I. fonhwilh comtly wilh lhos arovi\ions
<br />W RNTN-'G: Frihre k, sccure sutch comptnsarn,n covctusc is unla*tu|, ,trd chall subj.cl an crnpbys to ri,ninalFmhics urd
<br />civil fin.s up t, onc h!nl,.d rhotrsrnd d6ua {$100.m0). in uddnion lo rhc.o$ orconpcnsllion. &nr8cs !s provided lor rhc
<br />S..rion 1076.frhr Lnbor Codc. inrcrcs ntrd anorrcy\ fccs,",.ulnla n*-#
<br />DECI,AIAIIO!
<br />I h.rcb, annnr undcr r.nollyoiperjurylhal I anr liensn under lovnio ofChafls, (comnrncin8 wirh Sc.rion 7(xrj).loivision l
<br />of lhc Businc$and PofcssiorrCod.. md nry liccnr n,. tullrorc. and cfi6r.
<br />l;?tr g
<br />calslf,ucuoNLlxDllcA{ilxtI
<br />I hcrchyail r undcr Irnulry orpdrjurr rhar rhcr h tr con\rtucrt,n lcndin! ag.ncy ror
<br />'hc
<br />l)crformtra oirhc mrk for which rhis pcnnir t
<br />hsucn (Scc. 3l)o7. Civ. C.)
<br />APfu(Jlf![cLaf,InlrN
<br />I hmby ofm under penahy of pc,jury orc of rhc lbllo{ing dNlarlions:
<br />ocrn nn,. P€rmils.Asb.stos Nolificniion F.ncBl Rcgulolions (Tnt40. Pan6)
<br />Rcqun d kn$ olNotifi mlion
<br />-l
<br />ccnity$ar thc lcdcnlrcsularions rc8rdins Nl,csros rcnmvrl urc nor epplic,hlc ro rhh tmjc.r.
<br />-l
<br />ccnify thar I h!!c rcad rhn {pDcarion dnd sut. rhar rhe alr,lc inaorn ion h.ofrlr.I rSre ro coq)ly snh all Cnr ud Counry
<br />o'ninarces and Srarc Laws r&rins ro buildins con(rucriotr. and tcreh, ludernc (prcscnr0riv.s ofrhis Ciryand Coutrl, tn cnle. ut'on dE
<br />rhvc mnlioncd nrop.ny lhr inspccl
<br />ApDlicarl or Aaetrt SiaMlu
<br />lremil.e nam€(prinl):
<br />a l!1b
<br />III
<br />I
<br />II
<br />".r,.r",..,y'a
<br />L'"lr' .
<br />^J'lF..
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