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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Building
<br />Under Slab / Floor
<br />Bondinq i Groundinq / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilinqs (Hard & Solfit Rouoh
<br />Ceilinqs (T-Bar Rouoh)
<br />Meter Release
<br />al'-t *<Rouoh 5/E ,lv 1,iT
<br />Service Meter J*{>-?fi?\FINAL 5-B- rc
<br />Notes, Remarks, Etc.
<br />OWNER BUILDER DEI,C RATIoN
<br />I hcrchy afiirm unds nemlry or pcriuty lhd I m cxcmpl ftr,fr rh. G,nracxF l,i.cns lis for rhc rdlon'ins rcaan (s{.7011 5
<br />Busines and Plnfcs{rn C(xtc) Any Ciry or Colnq whi.h lcquircs t Ermir l. co.(rucr' rlrcr. in{rovc &'mlM nr rclun atrv .
<br />srru.rurc. prior b ns issuamc. d\o rcquircarhc alpli.mr for such tEirnil to rllc ! srgftd sdcnf,nl lnol tEor rh. is li.cnsd PuNuanl
<br />ro rh. [olhions ofrtE Conka.tn s Liccnsed Llu (Chnltcr 9, G,ftxn.ins wirh Sc.rbn 7lx)O.f Division ] of lh' Br(in's and
<br />Ptr,fcsn,ni C.dc)orthrl h.orihc is cicmfl rhcEftufland thcb.sir |orrhcallclcdcxctrrPlion Anyliolario.ofS.cri(nr?0ll.5l,v"ny
<br />rytlicrd lor . Frmir subjds rh. appli.rm ro s civ il penah y ol nol rmd rhnn nvc hlndEd dollatr ($500 r.
<br />l. rr owncr uf rh. pnrpcny. or my c'nnlortcs wirh w+cs as Ihcn sb comFnsd n,n. sill do rh. v( nlrh.iM@tmr
<br />i'n.nd.d or of,i'.d for slc l S(.7t}14. Busitrcs .nd Pmfcssion{ Coder Thc Conr.do s t,iccn* tiw do.s trot 0n vk, rnowncrol
<br />rh. rFFny *ho hoilds or inm$ lhcmn. snd *,m d{ts skh wo* hnn.ellor h.rslror rhmuSh hh or hcr osnchpk yccs.
<br />providcd rhar such impmremnkm mr inrcn&{.r oficrcd f(n s0le. tl howcw. rhc huildinS or inw.renEni h$Uwnhirom rlu
<br />uf.omplcri.n.lh. owmr Builder *illhrh rh. tirnlcn of pmving fid lrorshc dil to huiu dr ir{rorc rh. PmFny for rlE p!,lhe of
<br />-1.
<br />!s osrcr oa r hc roFdy. ,m crclusivcly conhcl ins wilh liccn{d conldctoF k, con(rucl lh. pmjer (Se 71114. Atrsin.\l
<br />and Ih'liashna'odc:ThcConxockxil.iccn\eLr{ddsnorntrlyt.onoqn.rofpn,p. ywhobuildsorimlro!.\rhcicon
<br />and who conrflcts Lr ruch r(,jccB uith ! conlBcion, licn*d po^unnr h lhc Contrlcl{,\ l,iccn* Ijw)
<br />lrmcrcnr undcr Sccrii,n .tt.&l'C tnr rhi. rcnnrn
<br />l)al.:
<br />-
<br />()*n..
<br />lvonxrns colrpplsarrot
<br />llEclA8Aua!
<br />I hcr.by nnnnundcr pcnall, ofperjuryon. orlhc following dcclmrioos:
<br />-l
<br />nlvc and will BinrsinaC.nirEn(cofConscnrlo Sclf lnslre ror s.rkdl comp.nsarion. ds rovidcd for hv Sccrnrn :17m ol ths
<br />tibor Codc. ftr rh€ ncrtomnft orttu wolt for shich rhc pcmir t L$xcd
<br />Ih,vca.dwillmai .itr work.lr comf.ns nrnin{.imc.$ tcquncd byS t ion ]7m of rhc ljho! Cnd. for lhc ncrn]mncc of
<br />th. worr ror which rhir rcnnil is issucri. MywDrkcrs conDcnsotion insutlncecanicr 0rn lolicy nun$., Tc:
<br />T.tlJurc*,|- La;'t-r,a\-t.\.\IL
<br />Iccnifyrhllinrhcpcrronunccolthcworkior shthrhnFi,nir is i$ncd l rhrll norcmpkry aryFr\on in anv 'ankrv, ,s r,' he(,m subiLrr b rhc workcs conrrcn\a|i('n laws orcrliltirir, and ssrcc rhar irI rhoul(l bccom ruhjcrr Io rhc
<br />tro*.n compcnsrrion prcvn,ons olSsrion l?00.rrh. trtxr cklc.I sh,ll hnhwirh.onDly qith r|os Povi\ions.
<br />WARNING tnilure r. srrc *orkcs .orrrcnsarion.oicriac is onlr*tu|. Md sholl suhFr (.mpr,,,rr ro aiminal Fn k! and
<br />ion. darogcs as pruvidcd for thc
<br />;,;ffi
<br />'' "i--it:uum'r
<br />llrrs ($10(1.([x)r. in rJdiridl nr rhc c.d of.omp.n\ar
<br />I h.nby,nirn undcr ncnrllyofF juryrhar I m licnsn undcr,,.vhionorchrPrs 9 (ommrcing wirh scrbn Tll)()roroivhnrn 3
<br />of rh. Busincssand Pmfcssion\ Code, dJxl my lkcnsc ii i. fullforc afrl.ffer.
<br />B.eoQ
<br />,",. MATTF-2IIIU;
<br />IaNIIAj]EUANIIiNIIISGIIiDNCI
<br />I hcrchy iflirm undcr rrnnlryofFrru.ylhol rherc is a con(dcri,n Lnd rS lScfty for rh. ldrortuNc oflhc *or[ for *hich rhis lqn l h
<br />is\ucd (scc 1097. Civ. C.)
<br />lxndcis N, t
<br />-A.IPUCANfDII;LdNAIION
<br />I hR1,y afitr udcr p+naky or pc.jury one ofthc aollowing dcclarart,ns
<br />DcmliionPcrmirs-A\llcdosNorifi.arion Fcdcral Rqulariotrs(lirlc40. PM6)
<br />-Rcquircd
<br />Irrrd ol NorilLdior
<br />-l
<br />cenily rh r Ih. fcncral r.sulariunc Egeding astr(os tcrreral arc nor applk,blc b thn pnjcr
<br />4€lcniry rl[r I havc rcad rhivpplicd
<br />o'ti'rh..s ntrJ srd. kws rcllr ing t, bui
<br />ah,vc nrnr nrcd pn,r.d, ror inslcdion
<br />ion arn slatt rhar Ihc lh)vc nrfoflori.n ii.orar. I ryre ro conply wllh,ll Ciry and Counry
<br />UnrSonsrucriotr. a l hc s Cnyrnd Counry ro emd upon thc
<br /> pDlic!nl or A*en(Sisn"turc ;t/ A'"N?q-t
<br />M,AY Iv 2011
<br />I
<br />Pole Bases
<br />Communications Cable
<br />n,.,*,.*. flAJ{\r{Co (31 (4o ,.',-..
<br />tind.i\ Addrc*.
<br />-T
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