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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDEN DELCARATTON
<br />I herel,) afliln lndcr lenah, of peri!ry rhar I d cicry tunr rhe Conrra.x,F Liens. hs lor lhc tolbein8 rclsn (SN.7031.i
<br />Burincss (n Profc$ion Code) Any Ciry or Counry shich reqxircr r Fmi b onsrucr. {lt$, imProv.. dcmlhn or rcNt otry
<br />i crur, lriorro ih iriudrc.. so rcquins rhc 0pplka ror such tfnlnr ro lilc a siSncd .llrcmnl lhalhcorshc ir liceoscd Nrsdl
<br />ro lhc pm*ions ofltr Conrncrors l-ienscd Lle (Chapter 9, Com@n.ing wirh sccrion 70(x) of Divkion.l oi rhe Ausine$ .nt
<br />Prcfcsri.n. Codc) or rh h. orsh. k cr.mpr rhcrcfrofl aM rh. brsis f.r lhc all.gcd crcryrriotr. Atryviolario ofSccrion7l).11.5brrny
<br />applica for ! p.iinit subj(tsrn opplicur to acivilpcnnhyofmr morclhln fiv. n!.d6d doUd6 ($500)
<br />l. d\ oukr of'hc pnlFny..i ny.mplorrcs with u,!.r.\
<br />'hcn
<br />sh.onrr.nsdion. willdo l,f, trtrk !r.l thc sltul!rc h mr
<br />i etrdcd o. ofi.rcd ror $lc (sR.?044. Busimss and Pmlcsions Codcr Thc Conlrocrol\ l,i.cnr l:w nocs mr applyi{, 16o*ncr or
<br />rhcpmFny *lil hoilds or inDmv.s rhcE)n. aJri who dB sch M hinxclf or lrr*lf or rhmu8h hN or hq own cmtloyccs-
<br />prcvidcd rhlr such imrolcmnls m ml hrcndd or otl'cr.d for {le.lf. howcs. rtf, hxildin! or iq,n,wmnr i! $Li $irhinorE }tit
<br />of.o Dlcri,tr rrE ownd aui$.r eill hl\r dc burd.n or pnrving ttu h. or slk dn mr buikl or i'qroE lhc lr,rEry ttr rh. purFt 6r
<br />-l-
<br />0s owner ol rhc F)pcrry- rm eiclurivcly conr.lcrinE with licenrcd conrruckns h .on{tu.r rlr Fn+r( ( scc 7(}l4. Busrmss
<br />.nd Pftfasin Codc Tn. conrr.ror's Li.cnsc kw des nor ,tfly b ,n owncr of tmtcny who builds or imtovcs rhcrcon,
<br />nnd wh,.onhcrslorsu.nrmircwirhaConrBcto(9ltcnsdplNunrrotll.ContucttrsLk.nr.kwr.
<br />-l
<br />hovc ud *ill minroin ! Ccnilrarc oa Conscnr ro Sclf lnsurc for sorl.B con{r.\.lion, rs ,rcvidcd lor by Sal ion 3?ur of lhc
<br />L or Gdc, ror rh. pdorrorcc oflhc *o* for which rhc,Ermil h issed.
<br />I hr\c aDd will mri' dn*.rk.rr.o iFnsrrn,n in\rrancc, n\ rcquircdhySccri ST(x)olrlrcLrhorC.ic.lbrrhcncrlonrRrol
<br />h. w'trk l.' $hx.h rh^r"r r Frucd Mt q 4l.^' omIrr \ricn 'n.u$ft
<br />( cJricr Jrd nnhc) nu mhcr 6(
<br />,",", (kk t"-,,t V.^t F c,a"l
<br />4 t+ l,idt - L, t1 It It
<br />Iccnifrrhriinrhc|rrrlarrntr'f,c()frh.sorkntrshi.hrhnNnirnissu.d.I\hnllnolcnlrloyiryncronin ntnHtrmr
<br />!, rsrr)l.dnrE \ubjccr lorhcworkcrr'.onDcn\rrion h*sol CrliI{nnir. rn{ll!ruc rl[ il I nn)uld hccotr* nrh]ccr ro rlr
<br />*ork.r\'con,|I0\rri,n,pn,vi\ionso{Sccri, lTfilolr[c l.aht Codc,ld]rll, nnrh*irlr corltllr srrh rho$ I)rovi\io's
<br />lv/\RNtN(;: Inibrc ro krurc *orkcr snnpcnsrri{in ..vcragc i\ ttrla*rul. anJ nrll nrl'jc.i .rr cnqnoy.r ti d nrinrl F-trrhi.s rnn
<br />civil linc\ up k, oN hundrcd rhoussnd dollrs (S100-OOiD. n, radirn, k, rhu.on ol .ontcn\rri(4 drnngc\ r\ prcvntd in lhc
<br />Sc.ri,n.rll76of rhc LrhurC,ltlc inrcrcd JnJurhrmy \fcc>,*",itultv n,,,,-^ CPt+lb et t urEtrfl(!,\lBA(ruf,
<br />IECI,AEAI(}!
<br />Y4LD /v71, ttl
<br />I hcEby alfirmund$ pcnallyofperjurylhar I om lienan u.dcr lmvnion olChaptcr 9 (commncinr *irh Sccri.n 7ur) oiDivnion,l
<br />oI rh B!ri*$ dnil Prof.s\ionr Cod.. ,rld my li.cn* n in tull fore dt cltur
<br />b -70 04'7 7
<br />tL":.Fe C vhc b,'v,(t..1+1'- Dt L
<br />CoNEIAISIQN.IINPING.6GENI]I
<br />I hcrcb, !fiirm u.dfi Fnahy of Frjury lhat lhcrc n ! mnsidclion lcdin-q ascrcy ror th€ Fnn.@@ .l rh. srk for whi.h
<br />'hh Fhil is
<br />hru.d (s4. 1097. civ. c.).
<br />AIjLICAILDIC|.AAAIIIIN
<br />I Iml,y afiinn unds pcn0hy of pcriury orc of thc lolloNinB dal<ions:
<br />Domlition Pc.mirsAsb.sios Nodnc0tion Fcdcral RcEUlrlions finlc 40. Pan6)
<br />Rcquircd tf,tt r of Noriftslion
<br />y*irhDllcirrntr(l (1 trry
<br />y rnd Cornry t,.nr$ qtun rhc
<br />-l
<br />ccnifrrhlr rhc acderal Esxhri.ns e!,rdi.g dit d.arcnmvr ,rc nor {tli.ahl. rorhis Dror..l.
<br />I.c iryrharlhrvcr. rhis ap,,licrlion uld sl,lcrh.r rhc ovc inionnirion G cotrccl Iasreloconrpl
<br />H*:":ilYiS-ruUZ* *'
<br />::,:'
<br />perm,kn.mc,pr,n,,: CP++{t- e - Moitvl>t ft
<br />rlLLltE
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Solfit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />Meter Release
<br />Rough
<br />Service lvleter
<br />FINAL ) 12/llq 4(f r rl-)
<br />Notes, Remarks, Etc.
<br />Air Conditioners
<br />I rm.\cmnrun,l., S(rion .D &PC lnrrhi\rrrynr
<br />lhl. ()nner
<br />EABtrI8S:I;OIIENIA.IIAN
<br />DECI.,A6.TAN
<br />I hcrchy rfir trndq pcElryorp.rjuryonc orIh. n,lk,*iDg dcclnrarnm\
<br />Lr.dci. Ad.lr.s
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