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ELECTRICAL.INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrcby 0ilirr undcr ncnall, or perjory rhd I n'n .xcmtr rh'n rlt Conirlcl,trr Liccn$ ltrw lnr lhc rolloPine rclsq (s( 70.11 5
<br />lJusincs\ und l!rnlc\*,n Grlc) Any City or Counly whrch r.qutcs r Fr.rir io co.slnEr. 0llq- iq)mvc. dc'tulish nr RFir any
<br />itucrue. prior ro ns issuancc. !l{ rcqlircarh. lPpli.anr ritr such!.nnirto l-rlc a stncd {dcft rhar Lorshc is liccnscd puFtur
<br />ro rhc proehions olrt Cookr.rors Liccnscd Lrp (Charrcr 9, Comtuncins Rirh sccrion 7tx)0 ofDivnion 1olrhc Businc$ rn(
<br />Pn,rcs\hnr Codc)orth,r rEorsh€ hcrcrlPr rhcrcf!.mdd rhc Uii\ ror rh. dLecdcrcDDlion A.yviolurionolSNrionTl)ll.5by,ny
<br />rypli.ont l ! pcnnir suhjat rhc appli. r ro d.ivilp.n.lryornor norclhan l'ivc hxndrcd dolltrs($500).
<br />-1.
<br />I o{8. or rhc tmF.tt, or Dy carplo}ci wilh *!Bcs as llcir v'k conqEnsal ion. $ill do rtl urk dn rh iME is m'l
<br />imMd.d or oncr.d lbl s0lc ( Sa 7044, Bu\incs snd Pnrr.ssn x CGlc Thc Conllrclois l-iceik tf,w docs not spdy lo un owncr or
<br />thc flop.ny who hoildsor inlm,h rttmn.ond who dN ssh Ntt himsclror h.rtlro. thmuSn his or kr{en cnployccs.
<br />nrovidcdrhat such nnpNrctrnls m nor inrcrH or otlcEa tur nL. It ho*w!, rtE bui*tiry or in{troEnEnr is sld wirhin oft yta
<br />ofd)rylcri)., itr Orncr Builhru l harc rhc hrdcn of pmving rhar lI or dr did mr huild .t iq'orc rhc ImFny fItr rhc l'uqr€ of
<br />-l-
<br />as owncr of rhc pnD.ny. rn.tulusiv.ly conk.cr in-q wnh lieosei conkrb6 k, .onsru.r rhc lo]ccl (56.' 7(x.1. Busirtr$
<br />rtrd l'rofssrn Codc: Thc Conlr.cl{r'\ l-iccn\c L!* dDc\ nor {!ly k, rn oqncr ofpn,pcn, $ho huildt or nnprolcs rhcrcon.
<br />rnd who conlmd\ fu s!.h p(&.rs wilh r Conh(k(t liccned pusuorh rh. Conrd.t,\ Li.ctrr li*r.
<br />I rcxcnrptunrlcrScclio a & IC.lirrhi\ rcrlnr
<br />DECI.ASAIION
<br />I lrrchya,li nulldcrpcnilyolFcrjuryoft ollhcn bwinedccldathns
<br />I halc dnd willnuinrain. CcniaEarcotG,n\cnrru Scltlnsutc fitr workcs' conlPcnsll t,n. os pR,vklcd ror by Scctn,n 1700 ol rhe
<br />L{hrr c(nr, iin rhc ,lcrroinBftc of rrE work for whict rhc ,cmil h isso.d
<br />Z4l r,o," ona * itt .uinoin *nrke6 conFnsarion insudnc.. a\ rcqutcd hy Sccr ion l?m or I h. t$or Conc. fot rhc P.rfdmkt or
<br />rhc $uk tu which this p(m r is issu.d My worrcB .o'nr.sarion insuErcc c!tricr aJd lx,lky ntrmb.r orc
<br />S\uk f,und
<br />q ?t )356t 1 6lzb/lb
<br />I ccniiirh0r n rhcrffomonccolrhr work inr which rhi\ Ponnir i\ is{'cd.l \h 1lno! cn,Iloran! Nr\in iD onynnnrr
<br />$ $k' h(onE suhicr x, rh. w(,rkds comp.Ndhtr h$s oaClliromia. trNl rlrcc rhd ill {nout Etonr srhF.r r'
<br />')Eworkcri NnD.n\slior ,tuvkhns .f Sccriofl .171X) oI I hc t-oh.r (bdc.l\ttrtl. r( hwilh..nrlly wilh lhot pR,{hnnrs
<br />\1ARNIN(i: Iiilu{ ro surc workcr conrpcn\nnnr corcrlg. is lnlntrltl. tnd nuu {]h,ccr an Mlll(,)t. ro critninal Iicnllri\ rtul
<br />rivil lid.\ un ro onc hundrcd rhoulrnd dolh6 (S|0O.O0O). in addntun r,lhc.o( ol.ontP.ns rn!r. drtrr8cs i\ rmrid.,t nr rh.
<br />\..ru, lt)r6or rlr lrhtr(ini. idcrcn rnn nttrmv'\ lcr\
<br />'d/1,"fi,2o/lo /lt<
<br />DEq.AAA.IION
<br />I hcrb, affirm undcr tenohy 6a p.riury lhar I eD liensn undcr rrovision ofChtrptc.9 (connmminE wilh Sedion TO00l.rrrivtion:l
<br />of th. Busimrs and Pmllssions Codc. s,ld ny Itccn* is in tull fore 0d cLal.
<br />(<LieNcNm$.r: lo I l qll
<br />*,", 5 /lo / .t<rc
<br />IANiIAIgUANIENIIIMiTIiENCI
<br />I lmhy rmnn n lo Fnully ol t riury rhar lhsc h ! onitudbn Lndin8 .8c.cy for rh. pdfornun.. or rhe wort for which rhis ,Irnit ii
<br />nsucd (SE :l(l)7. Civ C.).
<br />txrdri" Nsmc
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<br />APPLICAI\'T NFCLANATI(TN
<br />I hsd, aflim undc, lc.ally of lErjury om of th. tollosing dftldalionr:
<br />- ocml inn Pcirn r A.bci"{ Nnrficrr'on tcdcmlRctul,lnns rTillc40. Psn6)
<br />)A
<br />"-,,-o ,.u-, ".,.*,on-xa \ I rd riv rhar rhc l(tc' 0l Ee brion( re.rd'h, ash.{os rcmvtl !rc n"t amlr rbL ro rhk ,'mjcd
<br />ZDfccnify rh,r I luve rcdd rhis rpplialiotr ad (olc lhar lhc !tn!c infornnrion i oncl I asre ro ooply wnh all cil v lnd cou.tv
<br />ordi.atuc, and Sl,r. Laws rcl,ling lo b!ilding connruclnn !d hcicby,ulMrir rcprcscnralilcs otrhh Cnyand Counlvlo enlo lFn rhc
<br />nl!,rc trrrri,,nc(l Jinncdr,'r'n\t4-.crtrtrt t,!!r\c\6/)o 1/3Applirtrtri.. Agetrl Sians(u.e
<br />Zul
<br />@ru.4-
<br />," Ab,l1r"l
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bondinq / Groundino / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soffit Rouoh
<br />Ceilinqs (T-Bar Rouoh)
<br />It/eter Release
<br />Bouqh {/n /*<Th lrED.nCl
<br />Service [t/eter
<br />5AFINAL i/(stiE fl*l+*
<br />Notes, Remarks, Etc
<br />APPROVALS
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