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ELECTRICAL.INSPECTOR RECORD
<br />OWNER DUII,DER DET,CANAAION
<br />Ihcrct'ya irn !nd( pcnalry or pcrjrry ihd I an crcnfl rm (hc Conraclon Liccnsc l.a* r'or thc i,llosint ic,$n (s(7orl.5
<br />Bu\ircss dnil Pntc\siotr Colc) Atry Cily or Counry which rcquncs r rEmil ro .\,nnru( rci imptovc, dcrn ish or rcn!tr 41I,.
<br />slrudurc, orlo ns hsu0ncc. aho,cquncs rhc apdicanr t, such pcnnirro fihdligncd {atmd lhrl lEor shc is liccn\cd I,uFEnr
<br />k, rhc pmlhbnr ofrtf, coftacror's Licctr*d ti* (choflcr 9. &nnnrcncing wi,t S.crii 7(xx) of Divkion I of rhc Businc$ ond
<br />Prot$hns Codc) or thlt hc or shc is cicnpr lhcnfronand rh. h3\i\ hr rhe allcS.d crcryli.n. AnyliolarionoiSccriun 70.11.5 hy rny
<br />appli.rrrnapcmnsubjd.hlhcamli.arlo,civilDcnahyornolnNrclhlnfivchundeddoU s(!5ff)
<br />l, .s owNr of Ihc Imreny. or flry cnphyes ,irh wascs !s rhci, s,l. comp.nsdr ion. will do lhc ptrk oDd thc sltururc ir nnr
<br />inrcnded or .flercd nn ek (SE 7044. Brsincss and Ptuf.ssions Codc] Thc Conra.lot \ Liccns b* d*\ nor 0nfly ro an ow.cr ol
<br />rhc nmpcny vho builds or inDrcws ihcrmn. Md *ho dms seh w.rk hnnsclf or her*lf o, rhouAh ht 6t h.r own cmlloy.cs,
<br />prcvidnl rhar such i.rrn*mnr e n, intcnldl n oficrn nn et lf. houvcr lh: huildin8 or it{rorc'ft.t is eld wilhinom }lu
<br />olmndclh.. rlE Owncr Euiucr $illhave rlE hr6eo of pmvins lhi hc oi sh. did to buih or itrr,orc lhc,,mtEny for rhc purlb{ or
<br />_1. asosncrofrh. Fopcdy. rm.r.lusiv.ly.ontrfri,r8 wirh liccn$d .o.r racrou h.onsrtoc h. p6j.cr (s(.7(14,1. Busnc$
<br />nnd Prtrlc$inr Code Thc CotrlEt,, s LiccNe Llw d@s nor lpply t' dn owncr of p()rcrly who builds ot improv$ rhercon.
<br />rnd who conrhcr{foi ruch F.F.rs wirhaCo.r cto(s)Ii.cnscd Funurnt ro rh. Confactt\ Lien\c Lau).
<br />-l
<br />n cxcnrtl!trd.r sccli,'
<br />llslc Ovmr:wonriqs coMPENliarloN
<br />D[C]rlXAUt N
<br />I hercby lafirn ondcr p.ulry or Fj!ry on. .r rhc rollosin8 d8l,r ons:
<br />-l
<br />havc uxl willminraina Ccnificarc of Con{nr ro Sclf-lnrurc for workctr conrtEtrsrtioo. rs F,vided nnblSccrior 3700ol'hc
<br />Ltrtbr codc. for rh. p.rfo,r1ffic olthc qo* tbr qhich tlE pcn r n issocd
<br />lhr\cindxillmiinliinworkrri.o'nncnsrri(ri'nuBi.c.r\r.qui'cdhyScdtr.lTlroolrhclrhorC,dc,n)rrknrforh,rcol
<br />rh. s.rt ti)!*hichrhn Frmir i\ t\kd Nly workcd .onf{ n\dir i'Nunnccc{nicr r rnicynun,S.rdc
<br />Policy Nu'nbcr:-Expircr:
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<br />l.cnil,vl h rlr l.rf.i,rutrccofrhc workLr {hichrhis pcir}il i\ ir\ucd.l shrllnor crtpk,y! y ltsun in anynrn.ncr
<br />sd Nr) hcconE suh]cd lolhc so*c6 conpcn\rrion las\ oi Crlin,6ia. aftlaCtcrh iil dx'uldt conrc s!l,i{r hrll
<br />wo crr con{EnsrlionfmvntunrolScclion.lTll)otrnclnhnGnlc.l\hrll.ronhirith..mPly*irhlnorlroliliuN
<br />WARNIN(i Failur. io sur. wrkctr .onwtrsdtnr .o{asc is Dtrhwfi'|. rnd \hrll \uhj.cr nn cnrrlors ro sinrinal l)cnahts lnd
<br />.'r'l linc\ | kr f . hutrd'cd rlrou\rtrd dollnrr rSl([).lxxr)iri,nr ti rho co{ orr.tr,tr \rri. . drtrnscs l]r)vnbd tlr rhc
<br />4Lllly-^W,P
<br />C/D 7 1O
<br />o^. 4ZT/h
<br />IjANSIf,IIqUAN.LENDIICAGEIC.I
<br />I hceby trfirn und.r lErllty of pcrjury lhal rhcrc h ! aosltucrjon lc.dins ag.ncy ror Ih. l)crfornuncc ofthc wo.k lbr which rhh Fmir h
<br />krucd tsft.lo97. civ. c ).
<br />AfILIqANIDECI,AAAIIO!
<br />I brchynfinn undcr pcnol', ol lcrjury onc of rhc lolloainsddl Brionsl
<br />o.n irion Pcrnn$Ast c(os Nor irrcoriotr lrcdcralRc[ul.liotrs (l illc 40, P,nO
<br />R.quncd hlrcr of Nolm.alion
<br />_l ccnilyrhd rh. Icd.ral ftpl,rioh\ ft!,rdnre asb.{.s rcnn,r0lorc mr omlicrhle lo rhi phie.r
<br />I.cdifyrh lh vcrcadrh*dtlplrari a sIilcrhrrlhc l$vc irh ! io isconcrr lrgrmro.onflyNir[nllCiryxtrJCounr,
<br />n.dinri&\ rid Srrt L'qs nllrirs r' bu
<br />r6ok nEnri.ncd nmFny ntr
<br />Appli(!nl or Aa.nt Si|lmluft:
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />Meter Release =d-A
<br />7.uL,
<br />Rouqh -L ,/.K/r^
<br />Service ltrleter / l<6 */H
<br />FINAL ,/2 Z/lC tfr /\ 6-a1t *x
<br />Notes, Remarks, Etc.
<br />conshrcrion. and hcrcby aultrtri2c 'cpr.s.nrarivcs
<br />of
<br />:::'18';7)"6-
<br />Pole Bases
<br />I hcEhy alnnr lMlcr pculry or Frjury rh ! I anr liQntd u dcr tovsi()n ol (:hi/cr 9 (cotr,tuftn,8 *nh s..rir,n 70,$r ol Olvisio l
<br />ol rhc BusircsrtrM Profcsions Co(lc- rnd my liccn\c i\ in lnllfo.{r cfla.l
<br />tJn,tc, \ Jlr$
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