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E L ECTRI cAL.I NSPEcToH REcoH D
<br />APPROVALS ID/SIG.CQMMENTS OWNER AUILDER DELC]A&ATION
<br />I hcrcby ulfimr u ndc! F.olry ol Frjury rhar I an ctenfl ,mm rhe C.ma.k,^ Li..nr hw ro. lhc lollowitrB rc$on (Scc rOS l 5
<br />Burincss and Profc*ion Codc): Any Cny or Counry whi.h r.quncs a pcnnil lo onsrru.!, olrcr, inPn,!c, d. slish .r n'J{n any
<br />drucnuc.ltrior ro irs isum.. !ls. rcquiEs rhc rpllkanr Lr srch Fnril h lilca si3n.n sillcmol rhlr hc or shc is li.cnscd pn^unr
<br />ro rhc nmlisions of lnc Conr,acrors Licensed l-aw (Chrprer 9. Commrking wirh scclbn 7(x)o ol Divnion I oa rh. Brsincs dnd
<br />Profcssn,ns C.dcl or rhd tEorshc iscxctrrpl ri.rcfron.ndrhc bNt for lh€ allcecdcxcrqiion Anyviol iotrolSccri,trT0ll.5byany
<br />applicanlrbrrpcflnilNbjslslh..ptlicanrtoucivilpcnrltyotnolnlxcrhanrivchuhdi.ddollffs($500)
<br />-1.
<br />is o$ncr ol lhc I'()pcny. or my cmployccs sirh waBcs :\ I hcir $lc mnlFn\sr ion. eill d. rh. soA .txl rhc strruc k mr
<br />i'nc cd orofirrcdti)rrclS*'.70{.4,Busi'r.ssondt'rnf.\\nnr\Cnlc:lhcCinr..ror'sLiccnsliwdocinorlptlyhmoan.r.r
<br />rhc pmpcny wh. hoikls.t irqmtrs rhcmn. d $no d{xs sNh Rort hihscl{ or h($lr or rhrcu8h his or hd osn cnrhycci
<br />pmvided rhrrsxch ilnMmntsecnoli cndc\lor.ffcErt iG elc.li hMr\rr, rh. htr ilili,B or irgtuwnrnr is s)ld rirhifonc ycrr
<br />of.o'lplcri{nr.rhcO*ncrBrildrsillhnrcIh.hid.noff ving rhar lEor\hc dt Dor build or imfovc rhc IniFny for rlf, purli)\c ol
<br />l. dlowncr ofrhcni.Fny. rcxclusiv.lycotrkr{inS wirh li.cn\L{ conrrrroN k,.onsrru.r rh. pd,i.cr lsc. T(N4. Busrncss
<br />ond Ri.Lxsiotr Codc: lhc Conrrrcrol s l-iccnsc l,!w docs nor opp ly b rn owntr or ptuFrly *h. builds ot imPntc\ rhcrcor.
<br />,id whu onrEcrs ntr sx.h tmlcds wirh i co nkacton , I i.cnscd pusua to th. contucxr's Lift.\c tjw)
<br />I rnr.xc rt, tr cr Sc.ri,fl .ll & PC hr rhi\ rcx{,,
<br />Dole: O*mr:
<br />wot.(Fn.s' c(,t[PENs iroN
<br />IIDIIrIAA.IION
<br />I hcrcby,lfiirn undcr p.mlrlolpcrjury onc oillrc f.llowinB dcchrrlion\:
<br />I hrhudwill trrinriir rCcnifictrrcol'Contcnr bS.ll.lNurc tur $ortcn coDpctrunrn,,1 ,n,vid.dforbyScction:17u)oflhc
<br />Lahtr Codr. r'orrhc tsfoman.c of thc sork lor shi.h rhc 0.rnrir is isu.d.
<br />'hc
<br />aor* lorvhichlht arnnii is n\ucd. My tr orker' coopcn\di insurrmccuicr anJ E,li, numh.r nr.
<br />lcc ilr lhd ir rhc pcrfor nmncc olllrc *ork nn *hich ll,is ncnnir i\ i$ucd,I nrlltr.r cnr/.y.nt l)c6on ir any nunncr
<br />$ rs h hc.. * \ubjc.r ro rhc *o*c .otrrp.trsdn'n h$s.rcrliidtrir. md IlArcc rhar ial \houl(l b.coft nrhlxr k! rhc
<br />wnAr( .onrlf \ariotr lrovisio.\ of S.crio. .17(D ol (hc trt{r ( n,c. I shlll- fon h* irh omplt N irh ih){ lnrvhion!
<br />WARNINC t'ri[nc h scurc sorkc^ contxtr\arn c.krugc i\ tnh$tul. rtrd shrll \uh]ccr itr cnrll(Dq h oin,i.al pcmlris did
<br />cilil ftrs ut ro otrc hundrd rhor\a dolhr\ (31(x,.(D0). h JJdirnnr k' rhc.ost.r.onrtcn\rri.n. dimgcs as p(ridcd tr rhc
<br />Sccrion loTa olrll l.rhnGxlc i' crr{ aft] Jrorrcv\ lirs
<br />Dole: Appllenl:
<br />I ICF,NSFI) ('IINTIIACiOi
<br />ITECI.Af,AIIO!
<br />I hcshy,fllnn undcr FcnnltyorlFrjur! rnal I rn licnsd und.r lovniotr ofCholrcr 9 (connEncins $irh sccrion 7(D0) oiDivniutr l
<br />ol rhc Businc$ und Pmacssions CodL and m, liccnse is i. tull tuc and cn .t
<br />SNflA.IJI;uqI.IENDIITGAGENCI
<br />I hcrcbt amrm uid.r Fn,kyort'crjnrylhal thcrc h a.onsn.thn lcndin8 r8crcy tb, rhc rrfonnlncc ofrhc work ror which rhis Dcnnil is
<br />n\ucd (sN .loo7_civ c )
<br />lrxlcis Addrcs:
<br />-
<br />AITUIANLD!{:LIAAUAN
<br />I h.R$y 0iim undcr Fnalr, of pcrjlry om orrh. folk sin8 ds.'lnrrrions:
<br />o.nshioPc .iIs.Adrst.\Noriiicrii.tr ljedcrul Rcsuhliotrs(lirb,r0. Pura,
<br />-Rc{utcd
<br />Gxcr of Norifi cari(n,
<br />l.cnirtrhnrrlfr. .rdlrcSuldions rctrdirlA x\h*o\ rcnx,vrl r. .r rptlic.hlc rolhn [ojccr
<br />I.cdiryrhrr I hivc r.lld !hk 0Ipli..riotr ot srdc rlmr rtu nhvc itrronniriotr i\ coFeci. I arre n,comply wirh.llCiry and Counrt
<br />odmrmc nd srar. tjws nld inS ro ntritin8 conslru.rion. nnd h.rcby rulhoriTf, rcprcscnr nB .l rhn Ciry trod cornry t, .nr$ uB)n rhc
<br />nhovc nEnrt'ncd rot.n, fttr insF.'ion purF,\.s
<br />\rDli$nr or A(rnr si(nrluru
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER /o/tl(t 7 t4**a'
<br />Transformers .,1-
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Sollit Rouqh
<br />Ceilinqs (T-Bar Rouoh)
<br />IVleter Release Ut/r*I 4//W?
<br />Rouqh
<br />Service lVleter )ortlhp Fru*tlt"lh-./
<br />Notes, Remarks, Etc
<br />DATE
<br />Crricr
<br />Lir.n\cchs: Li.c.\. Nutr$.r
<br />I)8le (-irlrark,
<br />/4 Iltr /
<br />FINAL
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