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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER DUTLOER DOLCARA''ION
<br />I hcrcby 0firm unner Nnllry of plrjury rhar I d crcspr fDo lhc Co mclos Liictrsc Llw lor lic folbwnrg m.$tr ( S( ?0ll l.5
<br />Blsines\ and &ofesrion Codr)r An! Cily or cbunry whi.h rcquncs ! nrmil h coidtud. !h*. improvc. &mlnh o. rcp lny
<br />{ru.rm. rior r. irs hsufcc. .ko rcquncs rhc otplica.r lor such pcrnir ro iltu 3 sign d s.rcmnr th.r hc or shc h liccni.{ purN'ur
<br />n, rhe provi\i,'ns ot rhc C.nrador's Lic.nscd lrw lchall$ 9. CoNncncinE *irh Secrion 70m or Divhion 3 oflnc Blsincs and
<br />PrcrcsionsCodc)o.rhtrlhcorshciscxcmplrhcrc,iomoodrh.hashforrh.alLtcdcxonPtion.AnyviolalionofSerirn70115b,Ntry
<br />lprlicanr {or arE,mir sutjcch Ihc amlica.r ro a.ivilp.naxyornor mrc lhan nrc hundrcddollm (55{D).
<br />!. ds owrcr ol lhc prol.ny. or nry cmpk,yec. wilh srscs us rrEir $1. .onrrcnsd ion. will do rhc uork rnd rhc qrmlm is not
<br />i cd.n .r ofl'cred f{n slc (Sd T044, Busims and Prorcsions c.dc: l]lc Conrracttr s t-iccn\c ljs docs nor amlt lo an o*ner of
<br />rhcpn,lxn, who builds or inpmtu lh.]Nn. lnd who d(E skh *olt hin\clf or h.i\.lr oi rhroxSh hk or hcr own cmployccs,
<br />pn,lidcdih,r such im!rum.N m Nr inrcndcd oroiTcdl for sL ll hoscrcl rh. hilding or inlpruvcnrnr ir*,ld sihinoN rar
<br />olc! plclhn. thc Owncr Buitlq will htrvc rla hordcn of pmving rhd hc or shc did nol lflild or ifprole rhe ptulny ror llE I'urrDc of
<br />l. as own.r ol rhc tntcny. aDcxclusivcl, conlrudins *ith li.cnscd.ont!.i,rnio on{fl.r rh.lmict (Scc 71144. Bu\inc.l
<br />axlholt$bnCo{lcThrCo Er.r'sLic.6\.Lrsdocsn.rrtplyhanowNrol'px)pcdyshohrildsortnProvcslhcrcon.
<br />rid wh..ontm.rsrorsuchpmjcchBirh!Co rucro(n liccnscd rxisua '
<br />t,rhc abntradois Liccne L!*)
<br />I dncxcnu undcr sccho
<br />Dare: ovmr:
<br />woR{FRS', ColtlPi'Na?trI(lN
<br />ITIILIAAIJI}N
<br />I hcrcby rflirftrndcr pcnrlry ol pcrjut om ofihc iolloqin8 dccliralions:
<br />-l
<br />hak md will tuinrain . C.niil.rrc of Conrnr ro Scll.liF!rc hr $ortcr' ompcnsarn,n. as lmvacd nx $y Secrion .l7tD ot rhc
<br />l,ahor Codc. t r rhc pcrlortuncc of rhc *o.k lor which rhc pdmir is issucd
<br />I hi\rand *ill nDi iirworkc,rconDcnsrlionin\u,aEc-s\Equir.dhysNrion.lTIx)oithctjhotCodr-l.rrhcnrlormrnceol
<br />rh. sor* ror whichrhistcmir is nrucd. My wo,kcr' smpcnslrhn nrurun.. .Micr ttt ttlicy nunrbct sc:
<br />PolkyNunb..-ExniEs
<br />l.dnify ih r in rhc Nrfoi,Mncc oirhc uork l'or whkh rhn pcrmir is nsucd.l \hrllml employ trtry pcro. in rny rtrncr
<br />s nsrobccom suhjcd nrrhc worlicri cu nlpc n$r io n laws ol c,liroari{, rtrd {sErhrl il llhould hconr uhlccl to rhc
<br />wortcrs.ornncnsarionpmlist,n\ofsern,n.1700.frh.ttrtxtrC.dc.lsh0ll.fonnNilIconplt*irhrho*l)lovhions..
<br />.i!il lino\ uD t, onc hundrcd rh.t\r dollirs ISI(x).01x)). ir a{l{liri,D t) rhc.oq ul ..mncf1rtio.. dJr3.s r\ ffirrdrd lnr rht
<br />Sccrn,n 11076.frh. ttrhor Codc. i crcsl lnd ktrrcy s las
<br />,,,,f*125171&*,*',
<br />I hercby atlirn ond.r pcnalry or Frjury ttst I !m liccnkn undcr nrcvision orChapr.r 9(.o.rmnciaa wilh Sali,n 7000) or Division 1
<br />of rhe Au\incs snd Prorcsion! Codc. md my licctr$ is in lull foremdcllecr
<br />ro <(eQtZ
<br />,,","E-r2+ry";
<br />taNltr.&lEuoxl,lNlllNli-ac-ENlr
<br />I hcrhyrtftnrundcr p(ralryofpcrjuryrhrrrhdr hn.on( cri(,dhftlirtr8ctcyn)rll'^lrrln"ru,ccorrhctorkforwhl.hrhisP.nniri\
<br />isucd (se 1097.civ. c ).
<br />A.rtrlc NfDEcl,llaar&!
<br />ItElct,afrlmlndcrpcnnhy.rpcrjuryoncollh.lollowingdcclar ions:
<br />Dcnrlirion Pcrmirs'Astrsros Norifi cmn,n Fcd*al R.Cuhrn,N GirL /O. Pln6)
<br />-Requncd
<br />tlttcr ol Norifdti.n
<br />!.cniryrhar rhc fL'd$rl rc8rlurions rcSlrdinr oshcsros rcnDrrl !rc nor lPpli.,blc r. rhis lr!.cl
<br />IccnilirhulIturvcrcadrhisapplic,ri(n,.dsnr.rh rhcitx'vcinr'o.m ion n.otr(l lasErt,.onlplysithrllCilyundCounry
<br />o(Lrnrncc\ m(lShrc l,rw\ rclxiiruk, hu ilding oii ru.r dr. Md hcrc rrivc( ol rh^ Cirr_ nDLi(.ndy ro.rr.' trtu,I{
<br />rt\,vc N nnEd prcncnylor inslc.r ,,,.81 >rZK
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Founlains
<br />Signs (monument)
<br />Lite Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit),r*ao.'L+Y?
<br />Walls (Rough)'to )oe-(tv
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilinqs (T-Bar Rouoh)
<br />lvleter Release
<br />Rouoh
<br />Service [/]eter
<br />FINAL d-t- 18 -l/c9*b 'w)
<br />Notes, Remarks, Etc
<br />Under Slab / Floor
<br />LrnJcr'i AdJrc-
<br />ADDli.ant or genl SignaluE.$q$=t^
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