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ELECTHICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrehy allnm lndcr Fn!h, {)a pcrj!ry rhar I xn ci.nfr amm 'lE C.nkrchN l-iccn* bw ror rhc lolnrsirr8 Erstr lscc.7o.ll.5
<br />Busnrss ad h.r.$n,n Codc) Any Cny or C.rmy wnkh rcqunc* Fnni' k' con{rud. ahd, nn[ovc. dcmohh or Epli m,
<br />stru.rur.. ri(tr ro ns (suancc, als. cqutcsrhc applic r tr suchNnnil lo nb, skncd slolc Enr rl hcorshe il liccn$d ,u.umr
<br />r. rhe provisions otlhe Coorrrclor's Liccn\cd lis (Choprcr 9. Comntncing qirh Sc.lion 7tX)0 of Diviion.l ol lhc Bu{nrcs rnd
<br />Pnrf.s\n,n\CGtc)oirhrt hcorsh. ncrcnrlr rhcrcftum.nd rh. bNis forrh.llL8cdcxcmplion Anyviolflri,,notSc.rionT0ll5hymy
<br />apllicant Lr a pcnnir subJ€crs lhc lpplicanr k'rcivilpcn.llyolnoi nna rhrn fiv. hondrcd dolln^ ($500)
<br />I. as ow.f .f th. ImFny. or ary .,nplo)cs wnh waecs ,s rh.ir sl. com!.nsal ion. *ill do llE Bor[ dl rhc {tde n n
<br />inrcrdcd or otIcEd for slc (Sa ?041. Businc$ nnd Prcltssions Codcr Thc Conrra.rois t.iccnr Iiw de\ nor lprlyro Mo$mr of
<br />rhc pn,r.ny wh huild\ or impn)Er rlxMn.orn *ho docs skh hli hi,nsclfor hcMlf or rhmugh hil or lq own cnr,loydcs,
<br />prolidcd rhor such inDmt/Imnhnrcm{ inrcndcd oroltbrd frsah.Il h)qcv$,rhe hiHi.A or imlmrrmnr is wldwirhinorc }tr
<br />oa conplcrion. thc Owmr Buirtr sill tarc rhc lxrdcn of llovins rhal lE or shc dld nor huild or idpr.v€ th. pmFny fo. [E ,urtDs or
<br />-1.
<br />ns oFncr ol rhc I'mFny. rm cxcluriEly contnctine wirh li.cnscd conrret,,s ro ond cr rhc rmFr (sc.. 7oll. Businc$
<br />arxrEDr.asi,nCodc:Th.ConhacttrsLi.cn\.tjwdftrnorspplrroano*n..orprotnyqhobuildsornnprovcsrhcrcon.
<br />and {ho.onln.lslorsuchDmjstswirhoConrrodon9li.ctrsdpunuontrorteConrrlcrffsLiccnschw)
<br />-l
<br />ircxcnu undcr Sccl
<br />II}BtrEBIIIOMPJNIA.IIAN
<br />PECI.A8AIIQ!
<br />I lErcby afinm u cr lcnrllyotFrjuryonc of thc followine d.chralions:
<br />-l
<br />hrvc.rxl will minrair a C.fliff,lrc olConsnl ro Sclfitrsurc lor workcs $ry).nsrion. &s po{id.d frr by sc.lion l?0o ol rhc
<br />hbor c.dc. rd lhc pnrormmc of lhc vork lor which r hc p.rmn ic issucd
<br />I htrvcxtrJ silln,ri' rin sorkcrr c.'nFnsariod i'^urinr., s rrquncd hyS.crnnr:17(x)ofrhc ltrrhor(orlc,li.rhe pcrfonunccof
<br />.rq 'tL \l-rhrh'.8'ntrr'.'sd^lMtw rr'.','{tra1\.,rr1,tri.u'xi,c,.i!r.ilt..lhytrtrnh{rd,c
<br />rttttJ..r^,2<l c/4i\ :il,€.
<br />r)c-o-,o-\.\.\q
<br />l..niry rhrt irl rhc pc{onMmc olrhc work lor which thn rcnnn is isucd, I rhall nol cmploy lny pcr$n in rny man cr
<br />e i\lo hcco'm subjccr r. rhc wo rkc6' co mrcnsal ion hss olcalitomin- and nsnc rhnr il I sr()uld l^"*om ruhFct l. thc
<br />sorkcn comlEns ion Drcvhions of Sdn,n :l7m of rhc lih.r C,xlc. l shill. ronh*irh .on[ly wirh rlrc 8)vkions .
<br />WARNIN(; Fdilurc ro scuc "ortcrs compctrs.rion corcmte i\ unhwirl. ind shrll \uhicr on cmplorcr h aiminrl trr[hi\ otrd
<br />It'it'"xtt*Tgit:'r:r
<br />dollnis (Slm.(XD). ir {ddiion to lhc ro\l ofcoDpcns.rion. &nr"Ecs rs ttovidcd lnr rh.
<br />IECIASAIIQN
<br />I hcRby !fiiror undcr FMlly ot lcrjury lhlr I ah liensn undcr Imvhion ol Chapr.r I (omftftiog wnn selion ?000) of Divhion l
<br />of rhc Btr.ift$ and P6l.si.ns Codc, rnd my li..sc is h tull rora srn cfft.l.
<br />f)1oo1.tb1.
<br />fiAY ilflstfl -"**.
<br />g)NSIIJJqUONIENDING.AAINC.I
<br />I hcEby alfirn undc! IEnahy ot lcrlrry rhnr rh@ h a connrudiotr lcnding aEc.cy t, rh. p.rroimn.. ofthc work for which lhh pcmii is
<br />issucd (se lo97.civ. c ).
<br />AITLIIANIDEILAAAIIO!
<br />I h.Et y ilrnn trndcr pcnally of rcrjury onc ol thc follo*in8 d$lsrlions:
<br />D.mlnion PcrrnirsAqb.sl.s Norific.rion Fcderal Rcgulrriotrs (Tirlc,10. Pon6)
<br />Rcquircd l.ii.r of florifEari.n
<br />-lccni,irhal
<br />rhc Ldcril rcgullriqr regrding a\hc(o\ rcnovrl {c nor q,pli.nhlc t, rhilri.j$r
<br />l4-tunir,r rrr I hrrc rM ihi! rflrrnnrn rM narcrl rh{ro conply *irh nll Ciry r J Cuunty
<br />lrhnCirtutrd Couniy ro ctrrcr trFrllrcordi'rrncc\ rtrd Srrc Lrqsftldirg k)liurldr!
<br />xhov. nrtrri,n{ |B'Jurl lnr im|t.ri,trl
<br />Appli.rnr .r A,ttnr sitnrrure
<br />i
<br />lat
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding i Groundinq / UFER
<br />Translormers
<br />Torqueing
<br />Rool Top Equipmenl
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinos (Hard & Soffil Rouoh
<br />Ceilings (T-Bar Rough)
<br />Meter Release
<br />Rough €/u /r* s. ln',tFi)d1b
<br />FINAL 7fi/n '=Afd
<br />Notes, Remarks, Etc
<br />Sub-Panels
<br />Air Conditioners
<br />Service lrileter VqL.,rwu-
<br />tJ'tl.''. A'lJ'.$
<br />i)aq;l AtL*
<br />tt
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