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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDER DEL('ARAl'ION <br />I hoeby anm undd poah, oipajury thal I ar dcmpl from Ihc ContftcloN l,icec lrw fo. rh. aollowine rwn (SE 70ll 5 <br />ausir6s md Proasion Codc) Any City or Cou.ty shich r<ut6 a dmit ro conslrucl. ahs. improv.. &molish o, rqtsn dy <br />slrcru.. rior ro its issuoc., abo r.qrnB rh. applicd for such Fnnil lo file o siBned ndmd lhal h. or sh. u licm.d p@mr <br />ro rh. provisions ofrh. Conrlacrois l,i..nFd llw (Chaplq 9, Conmcncin! $ith S{rion 7000 oaDivhion I ofllt B6in.$-&d <br />PmGsions Codc) or rhnt h. or shc ii .rmfl lh6.nom dd fi. ba3ir fDr rh. aU.s.d crmpl ion. Any iolalion olsdion 701 L5 by tny <br />applicadforap.mnsdbje8tficapplicaDrtoacivilpn.hyolnolmorcllEnfirchundrcddollas($500). <br />l, d owncr ofllE Fop.ny, o ny .nploy6 wnh waSc s rh.ir sl. comp.nsal ion. $ill do lh€ woi. dd thc sltucl@ i! mr <br />inrmdql or orcr.n b. el. (Sc 7044. Dusin6s .ad hofssioN Cod. Th. Conracba! Li..B. bw dos nor 4ply to an own6 ol' <br />rhc pmFny who buil& or improvB rlm.. dd lho do6 su.h tr oil himscla or fifi.llor rhdugh hh or hd osn d!ploy.6. <br />,rovidslrhat such ifuprcrcndl' m nor inrdd.d or ond lor ek. lf, ho\'6q. lh. buiidios or iryotddr is $ld s ithb on. <br />'dofconDLrion. rh. Oq,n6 Builds will h.w lh. b8lin of provinB Ih, hc or sh. did nor build or imporc lnc Fopqly for lhc purpoe of <br />l. es o*ncr oflhc prep€nr. @ .rlusiv.ly .ontadin! wnh [.6s.d .ont adoB ro connrud rhc Fojecr I S( ?o14. Busrd <br />and rhrfBio. Cod.r Th. Conk0crois Licosc t-a\v do6 not apply lo sn o* n( of prot d! sho build, o! impmv.s lhssn. <br />and sho contncrs lorsu.h !6j(a wi'h i co.tmro(r li.d.d pmuant tolh. Conhclois LiceN l-as) <br />Itu ex€mpt und€r Sdion <br />ltaa(u&slcorflls ro! <br />DECIABAI]ID <br />I tu.eby afim under p..aty ol pdjury o.e of lhe aollo*inB dsltualnrnsl <br />I Mle md will minl.in a Cenifical. ofconsol ro Sclf-lnsur€ tor No,16' c.mrsMion. s txivid.d fo, by Sdion 1700 o f lh. <br />I-abor Cod€, for thc pcaol1@.e of rnc aort aor whict lhe pmnil is isued. <br />I ha\. and will ,nainrain Norkeri co,npcnsaliotr iNurance as rcqurcd l,ySednJi 1700oalhe t-abot(od., forlhc pstom ccoi <br />th. wor I for $hich this pmnil is issu€d. My sorl6 comp.Nalion i6ur&cc cdi{ ed pli., numbd dc: <br />/Afc45.ce <br />p"t*!N*,b-, - -.A-Dy4e]?tiJ ** '3L1::t. <br />l.eniayOar in rh. ptrfoflmnc. ofth.Nork for vhich this Fmil is issu.d.l shallnol onploy oy pde! it aty mmnd <br />$ B lo b.(om. subjel lo Cc sorkqJ compd$ion laws orcalilonit dd asre lhar if I 3hould b.com. subjEl to lhe <br />work6' com!.Nlion prorisioN olsstion 3700 of thc L,bor Codc. I {qll. fonh*nh omply with lhoF prcvisroG <br />IVARNINC: Failur. ro sdure trorLs comr.nsrion colcms€ is unla*ful. ud shall subjd M onplord to ainrinal FEhi6 and <br />.i!il 6n6 up ro onc hrndrcd lhouend dollas (5100 ). in addnion ro llr con bfco,bpeMtio.. dm.8e 6 provid€d lor lfi. <br />s..ri.. 1(176.frhe Irhrcod. inrer*r andt- '/e 1?e4 <br />pmvisio. ofchapls 9 (codmcncing wilh s<ri)n 7000) ol Di!hion l <br />of th. B6ins and ProfsnrN C.d.. ad ,.y lic@ t in lull aorc ,nd efldt <br />t3 qO ct<6 <br />I <br />ft/ zoz" <br />I hdcby afim undq Dorahy of pslury rnar th6c is a co <br />isru.d (Se 1097, Civ C ). <br />l-cnds'sNamc <br />ine aBm.y aor lhe pslom.nc€ ohhc sorl( fot *ni.h rhit ldmi b <br />AITLICANLDECI,ANAIIOtr <br />I l-er.ninn Md* Faally olpEjlry one of lhc followins d(lffilions: <br />D.dolirion Psnrirs Asberos Notificalion F.dcral R.8ularions (Tnle 40. P.n6) <br />Rcqun d L.rr6of Noriicarion <br />I c6lit th.t th. f€dcEl !.sulalioN rcsedi.g 6b6los ranoval c nor a$lic.bl. ro rhis prcjal <br />lccdrayrhar I haE rdd rhi! appli..tion ed $ar. thd rheobo\c inlomalioo is cotr.cr <br />.rJin3nrcs and Srnre t-a$sd.rnrro <br />ahinc nrn{0ncd lmtcnY lnr instcd <br />'\t)|)li(inl o',r{01 Sirura <br />md h.reby aft horiz€ reprMl sd Countyto alq uFnth. <br />/c/zo:-o' <br />Site-Work <br />Underground <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 />Building <br />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Transformers <br />Torqueing <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit)t a1 <br />Walls (Rough)Ll[.'./.{n ,*Y/bf,(a6^ <br />Ceilinqs (Hard & Soffit Rouoh <br />Ceilings (T-Bar Rough)I al <br />Meter Release i"r'flrt ,lbilbfla4 ,'l0Htqhcfre' <br />Rough <br />Service Meter , <br />FINAL ;/.e16?a Ab/t r0a t-d <br />Noles, Remarks, Etc <br />Sub-Panels <br />lhqeh) am' undcrr^-nalD o, Pcrrrllhil l Mr <br />I <br />=