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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrcby arfm lndcr penalry of Il.jury rh l am eicmrr from thc Conrradon l,i.c.sc tnw for fic rdlowing r.av,n (S...70]l5
<br />Bniin6s ard Prolc$ion Codc): An, Ciry o, Colnr, which rcquircs ! Fhln 'o con{ncr, ,l!(. inDbvc. dcmlish or Erat sy
<br />{rudm, Irrn t, ib i\surcc. ,ko Equifts rh. atplicd tu such pernn b nlc , sigmd ed.m tha' tr.r shc is licensd p!^uad .
<br />ro rn€ pmvisions of thc Conr6rols Liccn$d L3w iciaprcr 9. Comnrncin8 sith Sart,n 70OO of Dili\tn I .r rrE Brli"css and
<br />Pn,fcs*ionsCodc).rrhar hcorshc is.xcmpr rh.rclmnend rhc hq\is fd rh.rllo8.dcr.mpti.n. nyvioltrrionoiSslion?03l.5l,yony
<br />omlicanl fo!.Frnril subFclsthc nlplicrnllo ocivilpcn0llyolnol Dorclhln fivc hundrcddo]lm (S5G)).
<br />L as owncr ofrh. !$Fny, or m, cnplolc.s wnh *agcs r\ rh.ir tulc.omp.n$rk,n. $ill do th. wd* and EstMrurc is mr
<br />inEtrdcd or orcrcn ior sk (S.r.7tN4. Busirc$ nnd Prclcsions Codc Thc Gnlmtois Liccnsc tiw does nor lpply!o,n oetu'.r
<br />rhc rn,Fdy wlx, bdilds or imfl.rcs rhcm[ o whodGssurhk,rkhinrc]forhcrclforihouehhisorhlrow.cnDioyccs.
<br />pn,vided rhal such impmremnk N mr inrc.d.d ff oticred tu {h lt howcw. lhc $lildin8 or i'r{,rorctunr k sold {irhin nc Ftr
<br />of conllclion. rhc owncr Buildcr will h{rc rhc ttrlrhn ol povin8 rhnr hc or snc dil m' build or ir!trovc tlE pn,!cn, lor lh. plrF* or
<br />-1,
<br />rs nqncr of ihc pmrcny. !n .rlusivcly conrrr in8 wirh li(n*d conkrbN ro consrrucr lhc nrcjcct iscc 70,1.,1. Buirc\\
<br />rndttl,ff,siriCodc:lh.Corrr.r.isl-ic.nr.l,{wdocsnor!nI,lyrostr.wncrofptuprywh(,buildrori'ntrovcsrhcrcon,
<br />otrd who onrnrB for such !mi.* qith C.nlractor(s) liccnscd puNnnr Io thc Conrdols Ltcns ljw)
<br />-l
<br />nnrcxcnu untlcr SNtion-.3 &PC forrhGrcason
<br />Dole: oRner:
<br />IOBXISjij0MIEN! rlON
<br />DECLIaAIIA!
<br />I h.rcby !ffiirnundcr pcnalr, oipcrjury orc oirhc fdlowin8 ddlar ion\:
<br />I hovc 0rd willmrinldnaCcnificrrcofConsctrr ro sclf.lr*Urc ror w.rlcn .oDrFtrs.tion.0s nmvidcd for nyS*rtun.1700.f'hc
<br />bhn Cod.. for rhc pcrlbrmn...frh. *o* fdi*hichrhc ponir k h\ucd.
<br />-l
<br />havc and will moinrain rortcn comFnsltion insutorcc. N RquiBd l,y Ssl io. lTlro of rhc Labor Codc. lor rh. l.rlormfte ur
<br />wnichlhn pcnni i\ n(Ed Myworkcs .ompcN0riotr nNururc.er[r rftl lx)li.y num6.r uc:
<br />r.1.Ya.
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<br />ccriiylhrr inlhclcrlorronccoflhc wort hr rhich lhh pcirni n h\ucd.l shallnor cnlnoyany p.ron iomtnrMicr
<br />v, ,r t, bcc.nrc srhFr ro rh. wrrkds comp.n\ i.n l,wsofcrlinmia. mdaanclh ifl should tEcom suhJc.l rolhc
<br />pork.s o'nlf,trsrn,n pmvi\nrniofsdrion l70oofrhd ljbr Gxtc,I shill. Lnhwirh.onl0ly wilhrhos t'nvnions
<br />WARNINC FrildB n, sur. *ork.s .. f.n\rri(nr ..v.mgc i\ uihwtul, Md shall strbS.r M .nl!)lotrr to riminol ncnllris and
<br />riul iincs ut n, om htrndrrJ rlrusi d d.llr^ ($l(Xr.lxn), i'r t'ddirnr t, rhc.o{ ol.onrN nsalnnr. d.m8cs !s or,vnlcd for lhc
<br />socrnnr.10T6 orrhc ltrtxtrcodc. rcrc{ rdd arkn,ry \ lic\
<br />!EIIJBA.II!}!
<br />I h€rcbyailrm uMs p.nall, ofErjury th l am lic.nscd undcr prcvision ofChllls 9icommncing virh sdii.n 7o0o) ofDivision I
<br />of lh. Busims ard Pof.$ions Code. ud my li..n* ir in luu fom ,nd elfdl.
<br />\W.
<br />C(INSTRT'(]TloN LFNDIN(; A(;I]-NCl
<br />I hcrchy llllnn undcr pcnalry.l ncrjury rhar lhc,c is u onnrucli{nr lcndins !srncy lhr rhe pcrlonM..c olrhc work,br which lhis Frnril is
<br />issucd (SLr. 1097, Civ. C.)
<br />APPI,ICANT T)FCLAITiTII)N
<br />I h.R'by atrm undcr pnaky of Frjurt om ofth.lollowinS dcclnrlrions:
<br />Dcnrolirion Pcrnils Ashcsros Norificlrk,n Fcdcral Resrbrn,ns (Tirlc40, P,n6)
<br />-Rcq!ied
<br />lJrrcr ol Norifi clri..
<br />l.cnifyrh, rhc fcdeB|Eguhrions rcBffdin8 $h.sros rcnsv,larc nor amli.trhlc ro thh pr+cl.
<br />lal cenify r hrr I h(vc ,md rhN rrrliclri{,n dd {arc rhar rhc nbrc intondri.n n .otu.r t sgrc. ro conply wilh nll cny 0trd couniy
<br />ordinrnccs and Srarc Laws Ehlins ro blildins .onsrtucrion, ajd hcrchy auhorir! Erresedd,ilcs r,rrhir cny dd Cou.lylo cnln ullonlhc
<br />ahorc nEnrioncd p&!.n, lor insFrriotr purposes
<br />/\Dpli.rnl or A*e.l Si*ndurc
<br />9at.<-l A;q9
<br />Dels r
<br />Site-Work
<br />Underground
<br />Ljght Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Bonding / Grounding / 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 />Ceilings (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rough)
<br />Rough <7 b/,-t,€-PJFaia
<br />Service lvlqler
<br />FINAL *L+3 7 1/tr/l* ')wr
<br />Notes, Remarks, Etc.
<br />Pole Bases
<br />Under Slab / Floor
<br />Meler Release
<br />ltAY 1? 2018
<br />? A+.^,*** k-\r<{.a-
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