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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCABATION
<br />I hcreny aflirm undc, pcn.hy (,f pcrj!ry rhd I m cx.nfl nom rhc C.ntkroN Lien* tiw for thc foUowins @sn l$c.701 1 ,5
<br />Busincss and Profcsion Codc): Any Cny .r Counry whi.h rcqun r r pcnnil to oNlrucl. ahcr, iq,o!e- dcmlish or rl[n My
<br />srd.r!rc, prior r. irs krtrr...,ho rcqui rh.applicn.l for such lBmit lo filca sisncd sroIcmnl rhar h.o.rh. is lic{$ai ,ur${nt
<br />lo lhc !rcvisions of tnc Conrrucrors Licen$d Lrw (Chaprs 9, Codfttins whh Sccli.n 70oo of Division I olrhc Burinc* atul
<br />Profcsrions Codc) orlhnl he or rlr k crcnpr th.rcfrom drhc bf,sir for rhc dlcScd crcmtrion. Any violarionofserk.T0:ll5 hyut
<br />,ppli.rm ror r Frmir suhjels rhc ap,rliclnl to !civilpc.ohyofnol m,c rhsn fivd hundrcddoll,rsl$501))
<br />L ss owncr of rhe ,)ioJhy. or my.nltlk,y.cs enh *0Bcs as lhct so]c qnlrPcn\lrbn. *illdo rhc wo& nrld lh. ndurc i\ trur
<br />inlc cd or olttrcd fo. slc (Sa.?1I44- lrurin.s and Pror.sions Cnlc Thc C()nkNr.rs Licctrsc L.w docs nor sppl, k, sd.wmr.l
<br />rhc pbp.dy trlh brilds or improrcs 6cEnr und who de\ such wo* hims.llor hcr*lfor rhrou8h his or hcr owncmpbyces,
<br />ln ovnhn rhar su.n imprrrnf,nt m n.r ir cftrcd or oftir.d for sL. li howNcr. rhc huildirg or iqmetunr is s,lrl wilhin
<br />'
<br />{c }tJr
<br />or.o lPblion. thc Own r Buildc qillhnE rhc ttrdcn oa lmvins thd he or she dn k,l hui]d ot inpmvc fic PmP.rly tur rhc lorF,{ol
<br />-1.
<br />a\ owrcr of lic pmpc.ly. on ctcltr\nclr co rrrcting sirh liccn\dl .onr..k,F lo .on(ru.r rlrc pnj.tr (S( 7044, B \irtc\\
<br />,nd PmfL*iD C.dc: Thc Contrrclols Liccnsc Law docs not annly lo rn o*ncr oapmD.ny trho builds or improrcs lhcrcon.
<br />lnd *ho conulcts lo, such Imjcclruirh!contn t'n,Iic..scd puru. roth.G'trtrclois Li.en* li*).
<br />-l
<br />!Dcxcnu undcr Sc.l
<br />Date Olner:
<br />WORXFRS' COMPllNSATXIN
<br />II&CLASAIIQN
<br />I hcrchy afinr undcr FntrltyolFrjuryoic oilhc t,llowinB d(ldarn n!:
<br />-1horcond$illnEnsinaC€nificsrcofcon.cntroscltlnrxdforqorkc.onDcnsulion.!\pmvidcdfttrbys(rio.:l7moflhctjho! Co{c. lor lhc nc ormrcc of rhc nuk lor shich rhc ,lmn t is{cd
<br />I hrlc rnd sill nainrrin qoikcrC c.nrNnsd i()n iNulamc. or rcqutc.l l,y S(r nnr .l7lx) of rh. tj}xtr Codc. lu lhc pcrlornBmc ot
<br />w.*e^ compen{rion n6uranc.cri.r arxl lBlicy numbcr uc:
<br />tlrr'.rJ \N l-(^RA(*a r.\.\1v
<br />I.cdily rhrr ir rhc pcrioirnancc,,frhc $ork li)r *hi.h rhir F-iinir n issur\|. I \hnll nor cmnl(), !rry pcron in rtry mrn cr
<br />n, N t' li(1nnc \!l,Fcr ro rhcworkcs'cnn{cn\oridr lNvs ol C0lif trin.0ndrg(rrhrriflnx'uldlEorrsublcdIolhc
<br />worklA.o'hpcisrtio pn,visotrr ol SLrlirnr ITUJ of rlr tihor Codc. I sh,ll. fonh*ir[ $ 1pl, wirh rhoe U ovhion\..
<br />W RNINC: I:rihtrc to scwc rorlcF .rn.ncisaiion Lov$rsr ls unl.wrul. rnd rhnll suhjcct 0n eniphrcr ro d'nirdl Ftrrhiis rtrd
<br />:r*AY}:r"rySt**
<br />,lol['\ lSil[).(xr)). ]n r(l'liri({ n, rhr..
<br />I lrcr.[y!lltnrundcr nrnrlryof |1.']uryrh l air nhvision oiChrnrcrr) (.onnJf,ncnr! rirh Sc.tin ro(x) .1 l)n i\ittn .l
<br />nr rlr lhrinc\\ 3nd P.ortssions c.dc. u nlv liccd\c n i'r full nmr :nkl .ll.d
<br />@ /oo1"1,aaq
<br />CaXSIBUqIIaNIIIDIIIj.&CTNCI
<br />I lrrchy,flnm unds lEnalty of pcrJurr rhsr rhsc n a.on{ru.rion kidinS agc..y hr lhc p.rlormrce ofihc sork rot whi.h rhis F.nril i\
<br />isurd iS.. .1097. Civ C.).
<br />AfIUCANLDECI,ABAIIAN
<br />I lerd,y,{inn u ndcr r.hahy olr.rjury orc ollnc followin8 declamtions:
<br />Dcmolition Pcrnrirs Asb€{6s No n. ion Fcdcr.l Rc8ul0l ions Ont 40. Prn6)
<br />-RcquiEd
<br />tillerof Nnif'.arhn
<br />l.cnif lh rhc Meril rcsu {rnnF rcsrdin! ash.{o\rcnDvnl trrc tr.r rptlic,nh h rhn poJccl
<br />- !1..niry rhd I h,v.,.ad this .tplicdn,n ond.lurc rhor rhc otnvc i.folmrion ir I rgrN lo.omtly qnh oll Cn, trnd cornrr"
<br />oftlinr'r.\,nd srarc trwsrclarinsb buildio8 con(rudion- a llhn Cilyand Colnry h tnr$ uB,n rlt
<br />nhovc ntnrioncd pDFdy tur i.st .rnntputt,\cs.
<br />,,\ppli(ml or ]\A.nl Si,rnnlurc
<br />I )o-",',.1I Ar,'?^
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Founlains
<br />Signs (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueing
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />It/eter Release
<br />Rough f/rL,/iV 5.'velzn+frl
<br />FINAL b/Q.q/h >D rb
<br />Notes, Remarks, Etc
<br />Sub-Panels
<br />Service l\,4eter
<br />I .ndcr'. 4 i,Irs
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