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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCNRATION
<br />I hcrehy !ffrm udcr Il.nah, of pcrhry rhar I d .xcryt from rhc Crnrrn r6G Lk.M b* ft,
<br />'he
<br />follo*ing r.asn (S(.?oll.5
<br />Busin.ss {ld Prcfersi.n Codc}: Any cnt or county which ftquiBs i Fnnir ro onidcl. !1t6. impmye. dcm'lirt or rcnsi uy
<br />sructuc, prior ro ns issu!trcc, o rquncs lhc sppltant lor such Ilrni k' lilc a risncd sllrcftfl rhll & or ch. k li...(d Pummr
<br />ro rh. povhbnr of rhc Conr.d.t r Liccns.d hw (ch+r.r 9. commn.ing wirh Scction ?filo of Divisiotr I of rhc Buiincss atd
<br />Pmfcssions Codc) or lhll hc or shc is€rcnfl lncrcfnn otrd lh. host for rhc llks.d eieq)iion Anyriohrirmorsc.rionTosl5 by {ny
<br />dpplicanr ror a pcmn soblcck th. amlicam ro acivilpriahyornor moroda. fivc hlndred dollcs ($500)
<br />-1.
<br />as oRrcr of ih. pmpcny. or flry cmployes wnh woBcs !s lhcir olc conq'cnsal ion- wiU do rhc work snd rh. imrurc i\ nor
<br />i cndcn or olicrcd lhr sih (Se_.?044. Businc$ and Pmicssiotrs Cods Thc Conk!.lors l-kcnk Liw d.cs nor lnt'lylo nnowncr ol
<br />rhcpstfny who buildr or irv,mvcs rh.ron. rrd Bho d6 seh m* hinsclf.r hcrsll or rhou8h hn or herown cnployccs,
<br />pmvidcd rhar such imlhv.ftnh d fr, inr.ndcd or ofici.d nr eL. Il hoqcvcr, rtr ttriltmg or inDmEnEnr h bld sirhin om Fu
<br />ol coq,ldion, ilE Owmr Buiklc, will huw rnc brdcn otprovins rh€! hc or \h. dil tr.r huih or inpmrc thc psFly lor lfu puqns ol
<br />I..rownmofrh. !mp.n y. .h cxclus ivcl, contr.ling wnh li.cns.dcontricrorsroconntucl rlE pmj€l (Scc ?044.8u\ifts
<br />ard hofsshnCodcr TncConlractors l-iccnr l,awdocs nolarplyro Mo*n.rorpmp. y *ho builds o. nnfmvcs thcr$n.
<br />and sho comrers n, \u.h ,,nj.\h wirh Comacb(r) lkcn$d rusud n,rheConkcrols Liccnsc hw)
<br />I rmcrrrpr undcr S..r()
<br />W()RXERS' (ll)MPI,-NSA f ION
<br />DECI"AMI]AN
<br />I hcrchyrftn ruiddrFcnnlryolFrluryon.oflhclollowingd..lardtiotrs
<br />I h!v. ard will minrain d Ccniltrdrc ol Conscnr to Sclf lnsur. lor worlcn conf.nsdion. 3\ Imvidql lor by Serion ]7u) of rhe
<br />tjlxn c{dc, fu rh. pcrfoM.. of rh. *urk id whi.h rh. Jxmn i< isrusl
<br />-l
<br />holc .nd uill
<br />'Minlrin
<br />workcs cotrllEnsarhn insuEmc. as rcquircd l,y Sc.rion l7m ot rh. tihor C-odc. tu rh. ,nforrorcc of
<br />lhc work for whth lhk,Ennil is hsEn. My workcrs €omp.nelion itrsunmc cartr and Flty nuftb.r @:
<br />"^-*,, 9*1e {und
<br />qzl l3s'i l 1 5 zk lx,
<br />Iccdifyrhar in rh. pcifonnr c.frhcvorkfuwhichrhi.$nnir ir issucd. I sh.ll nor cmtrloy any pcAon inant'nrnncr
<br />so !s ro bccom suhjccr lo rhc wolkcn'comrcns ion hws ol'Clliixnia. and astuc rhar irl sh.uld h.&nrsbicct rorhc
<br />wortcn' conrlrcnsution Inovhions ol Scdion :1700 oi rhc Ltrhor Codc. I \hnll- r,,nh$irh .onFly wirh rho{ I)n,visios
<br />'A'l',i 1|nc36
<br />S.zY it
<br />cotrslf,lJcnolttENDaclc[lcr
<br />I lf,rcby!,firm urdcr rEmlryofF jDryrh!1 rhcrc isa cond crion !.ndi.8 a8.my for lhc p.rformrc ofuhc *ork for {hich thii lFdn ir
<br />hsued isc. 3097. Civ. C.).
<br />ATIIICANfDECI.AAAU!}N
<br />I lErd,yanimrundcr pcnalty ofpcrjur, orc of rhc tollo*in8 dcclmriors:
<br />Dcnblilion Pcrmils-Asbcsros Noiiricllion Fcdcnl Rqulolions ('rilE 1.0. Pnn6)
<br />-Rcquircd
<br />t rtcr of Norif{.lk n
<br />-l
<br />cslily thar rlE fcdcnl rcsllr' ioos Esrdi.e f,rLdor rcn'ral,i. Nn,rpli.ahlc lo rnis pojccl.
<br />EU ftdiry rhd t tuw rcad rhk trppltarbn,nd sr,icrh.r $c ahovc inroi,urio. is coftn I a!@ ro ohpty wirh dllcirrrnd counry
<br />reprcsenrarives ofrhk Ciry and C.unryto cnrn urdn fic
<br />,,," s'2J {8
<br />la
<br />xtxn. nrnrnrncd ptr)pcn! lnr instr(r
<br />u"-n*.".",rn*,, Kfn b< rl-1 l,t nzu4
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondinq i Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soffit Bouqh
<br />Ceilings (T-Bar Rough)
<br />It/eter Release
<br />Rough HzzlrC -Aa-qfi q)
<br />tl
<br />FINAL lt /{,b lg 5b€rX
<br />Notes, Remarks, Etc
<br />Pole Bases
<br />Service Meter
<br />WARNINC: F.ilur. ro suc workds mmpcnelion .o!.Bgc is unlowtul. otrd shrll subj.{l an cq,lo,tr ro dninal IEMhi.s tnd
<br />chil fines xp ro o.. huMi.d rhous.d doll6 (Slm.ooo). in lddnioo lo rnc cosr olcomp€osario.. ds@gcr 3 rovid.d lor rh.
<br />Serion 1016 ofrhc bbor Codc. inhrcn ad arromy s lccs
<br />,,,., 5 zYrls n,n^,.# V&4&--
<br />LIcEMED-lllNIldrroi
<br />DECI,AXd]IQ!
<br />I hcEbyomnnuodcr prnllryofncrjuryrhdl I rln lien!.d undf Fovkion ofCh.ptcr 9 (ammncin8 with Sdion 70()()) ot Divi*ioo.)
<br />of lhe Busirc$and Pmlbssions Codc. anl myliccn* n in nrll forc and cfter
<br />L.ndcis Addrc$
<br />-
<br />Applicsnt or AI.nl SiEnnlurc:
<br />II
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