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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUII-DER DELCARATION
<br />I h.Eby arfirm und$ Fnrky {,f p.tjuy rhd I er cxonpr nom thc Cotrrrocrim t,iccnsc l2w tor rhc folle*ing rt$n (Scc 7031 5
<br />lusincs .M Profc$iotr Co{c)r Any Cily or c{Dnl, which RalriB a ,f,i,nr ro connrud. dl.r, inlltrorc. {bmnnh nr mFn rny
<br />dd.rurc. Iri.r !o ik hruanc.. rlm rcqun s thc r,'dhant ror su.h Flmi o lilc tr sisrcd sraremnl lhar hc or shc I li..n*i Pursrnl
<br />ro rhc nmlhions of tlE Conrract ls Liccned L2w {Chrpter 9. C6'nncn.in8 wilh Scdion 7000 ol Divisn'n 3 of lh{ Bu1in.$ r d
<br />ProtcsionsCodc)orrhnrhcorshciscxcmprrhcrclrom,Mlhcbasisrorlhc0llc8qlcxcnrplioi.Aiyvi{n!ii.n.rscciion703l.5by0ny
<br />nprlicrtrr ior r pcflnir subjcctslhc applicsnl ro !civilpcnolllol nor morc rhxn rivc hutrdtu'ddollas(55lxj).
<br />-1,
<br />a\ owmr or rhc tr,tEny. or my .mtloyes wirh waecs N lh.n b[ .omFns ion. sill do r,E krl dd rh. { 1mtmr
<br />icidcd.rofiircdlorsLlSR.To44.BusircssandPmlcssionsCodeTh.Colrtlcroiil,t..seL,*dl).snornpplyloano,rcrof
<br />rhc pmrcny *ho brit s or irqimh rh.tu( riqhodesrx.hsrkhin\.lforhcrcllorrhrouAhhi\orh€rosncntrlo)t.(
<br />Dmvid.d lhol su.h imloErnh m mi inrerhd or oocr.al for sk lf. l$wcvci. rhc huildin8 or impmtmnr is eld *irhin onc Fr
<br />ol conq,lction. rhc owncr Buika *ill how ttt hurdcn of fmvirE rhnl hc or shc did n, hill or inpmw $. pmtd] lor rhg puqD* ol
<br />l.asowncrolrlEl'o|cny.!mcxclu\ivclrconrrrcrirsvirhliccnscdconrrrkr{t,.otrdfl.'drrft}-tt(Scc7(!4.Bu\itu\r
<br />nftl Pnfc$ionCodc:l'hcConrrctr'sLi.ri$Li$doc\norrrplti)r0o*mrolnmpcrly*hoI'uil&.ri'nrruv$rhcrcotr.
<br />.nd *lr .onrd.htur .h tnoj.rls *irh ! o)nrruurrn(s) lkenrcd nur\urnrkirhcC. t,.roi( l-iccnsc ltrrw)
<br />I omcxcmDr undcrs.crbn .8.&P.C ro' rhn rea''n
<br />rvltxxt Bjlrout[lst-ll!)N
<br />DECLAITIII}N
<br />I h.ruhtrflnnruDdcrI[trxhrol 0c'juryoncollhcln Irvirg u.liroons
<br />Ih3vc d lill n' inrtri u C.n ifl.drc ol cotr$nr k) scll l trsurc Lr r$kci\' conrFnsxrion. r\ pn)lidcdntrhyscdion:1700olrhc
<br />lrhrr Codc- f{rrhcpcnbrmrtuc of th. work Lrshi.h rhc Frnrir i\ issuci
<br />lhrk rnd tr,llnuidrin $orkcri conrF-tr\ari,r nr{uinncc. r\ rcquircd hvSr.ri,n.17(Xrofrhc l-rhor(inlc. i,n rhe Pcrforturncl ol
<br />rh. sork for ehhhrhis pcirnil is hsucd. Mrwortc oTcma'ron rnsruna urt$ nnd Fricy numbn ml
<br />Nhrh rhis pcflnl n isncd.l \hrlLnoledrl{yrnrtrr{r' in itry.'m.cr
<br />Ri A ro hsm subF.r ro rhc rorts{ conE.slrion hws or Caliio,oia. nnd asRc rhd il I should bcorE tubjccl lo r}r
<br />soir$' .onn trs,r ior thvi\rns of Scl ion l'7(x) ot rhc Lahor Co<lc- I shllt. rod htr irh .omPly wirh rtus Pnvnions..
<br />lv^ltNNc: l'aihc l, {.urc wo,kcr. co ion.ovcriac i\ uild*tu|, dnd shrll {rbjal in cmploy.r ro aimind Fnrlri.s rnd
<br />.N I lni.s uf r(] ofr lrtrn(lre{l rMu\xn,l doll rs l(xr.Ox)r. i', l irrnr ni rh. cosl .l .onDcnsrr on. drnlg.\ a\ prrirlcd lar rh.
<br />sccrnrn 1076 olthc l-.hn Ciidc. inlcrcsr
<br />"",".r-1/2
<br />l.l( 1.:\\l.ll, ( r,\l lll( llrt
<br />DICI.ABA.IIIIN
<br />I hcrcl,y afiirm undcr FnnlryorlE jury rh.l t am li.cnrn undcr povisiotr oI Chaprq 9 (comncing wirh sccrion TOUo) ofDivisnnr.l
<br />of lhc Busircs md &ofc$ions Codc. ind my li.cn* i! in rull rom dld efccr.
<br />'7 6/ <//2
<br />2 2
<br />V
<br />C(INS'IRUCTI(}N LENDINC AGFNCY
<br />I hcmby rr6.fl undcr tr trllty.l pclju.y lhal lhsc h. s'nsrruclion lcndins ascn.y fttr rhc lclformmc oflhc *orl lor whth rhis lEnrir i\
<br />i\\ucd (Scc :1097. Ci! C )
<br />AIPIL(;AILDLCLAIAIII)N
<br />I h.1rfiy alim undcr Fnalry of Frjury or ol rh. followi.g dslnmiions
<br />Dcmlirion Pcrmih-Alhcslos Nolificlli.n Federll RcBohlions ('rnl.,ao, Pda,
<br />-Rcquired
<br />Lcrrcr of Norifrcarhn
<br />lccnifyrh r rhcrid.rrlrcgtrl nns rcE lira !sh.no\ rcNrvrl rrc for Jtllicrhlc brhi\ pnicd
<br />ordimNc( rtrd Sralc l-rssrcl ingk)
<br />trhovr nrnrionc.i pfl,Ir rt r(n ir$n .l
<br />ldins conirucrion. !M hcreh, ru')nrn. mp,oscJlljllta. orthn cirylnd cou y i. $rcr qrotr thc
<br />1|l|lli.,nl.r,\scnl Sisniluru
<br />-?-y tr:la--z/eLe
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm i Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Rouqh
<br />Ceilinqs (T-Bar Rouqh)
<br />lvleter Release A
<br />Rouqh ld -1-ttr hs4.t0)
<br />Service [/eter LA
<br />FINAL lo-25-lg x.v+$
<br />Notes, Flemarks, Etc.
<br />Site-Work
<br />_l.cnify rhar i! rh. prrf,trtruieof rhc solk
<br />I
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