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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDER DELCAI'A'TION
<br />I hc.cby !fion undcr tc@h, {,r Frjury thal I on cxenDl lru rhc Cn rrcror' Liccn* hw ror rh. ,nlbwing rcasotr (Scc.'7011.5
<br />Busi,rrs and Pr.r.ision Codc) Any Cny or Counry Ehi:h rcquncs s Frni kJ erBrru.r. ah.r, nnpmvc. demlish or rcpan Mt
<br />sddDrc. prior lo its issuamc. !l$ rcquircs lhc aptlic.nl lor \uch Frh h fik a siSmd slutcmnt thlr lE ot sh. n lil!.sdl lur .nl
<br />lo thc provhions ofrhc Conkacroir Liccnsd bw (ChaDrcr 9. Comm!rcin8 wilh Scction 7fin ot Divtion I ollhc Busincss and
<br />PnfcrrnnrCodc)oirhartrorshckcxcq,tihcrcnomandlhcb0risforlhcrllcstdcxcnfln,n.Anyvnn.lhofs{tio.7(,:ll5brriy
<br />(tpli.antlorap.nitsuhjalslhcspplicanrroacivilpeoalryolnornncrhnliv.hundrcddollors(S5OO)
<br />I. ,r .wmr oi rh. pmlrny. or my cmploFcs sirh *oscs rs lncir $L orq.nsarion, will do rlE \olt ald rlE nBim ir frr
<br />inrcndcd or olIcEd ntr sb (SE 7(E4, Burincs and Pror.$ions Cdlc: T)E Conrrocrols l,icense tiw do.1n.r arPly k,.tr owncr ol
<br />rhcta)pc'ty eho hoilds o. iflatoEs l&F.. ond who d@s such urt hims.llor h.sclfor thouAh hh.r hc. o*n e'nployc.i.
<br />pnvidcd rhar srch nnpro*dnr* m nor irtrcftlcd or .ftEd nn srlc. l( how.tr, rhc buildin8 or ir0mwntnl h sld wirhin .nc }tr
<br />ofcotrplcriotr ltr ovner Auibcr rill hlw rlt hxrdcn o{ psdns rh,r tr or sh. dir mt boi}d or iqrere rh. rnrFiy ror ttE tdrlnE oI
<br />l. u\owkrorihc p(,!.ny. Mr.nlusivcly coDtrcr ina wirh licc,\cdconrrldoFroconntu.rrhc r(,iccr (sq 7044. Bu\i"t\\
<br />ond fttlcrion Codc: lhcConrractr\Liccnsclj*ducsnor!p!lyroino$ncr.,proDcny*i(,huild\orn$rovcsrhcrcoo,
<br />and uhu.onrncRro.suchtn'FlswilhrCoolBctu(s)licc.sdpui\Mdn,thcconk (tr\ Liccn{ L!w)
<br />I rmc\cn,pr uidcr Sc.ror . ts & l'l( li)rrhis rlrvnr
<br />Dalq O*n.rl
<br />WORKFRS Cl)Ttf EITSAT!()Ii
<br />DECIAXAIIIJN
<br />I hcrcby oiltmundcr pcnlltrofpcrjutyonc orrlf L'llowirg dNldratiotrs
<br />I htr!€ hd will tui.rdir s Ccdlt,rc oi conscd ro Sclf.l nrurc r'or workcr' codFnsnrion. as povnlcd ror by Sarbn .1700 or rh.
<br />Lat or Codc. for r h. pcrronEkc or rh. work ror whi.h rhc rrmi( is irsu.rl
<br />Ihrvcddwill x'ir in workcrr conD..srrion iNurJrcc- a\ rcquircJ hySc.rn,n:17(XJ(
<br />rrtr,rli'{trhkhrhhf.InJri.r-rl M)4, \c'J.. {Irla,'ri,.r 'n.L'xi!r.Jnicr.'1d F
<br />cdh* vhra(u.^ask c-+V Ltts.
<br />)fihc hbnr Codr, f(r rh. l.rnrnrNc ol
<br />Drr.-rt .,.t Co o+o ct
<br />-lccnilyrharinrhcFrfo.Mn.rofrh.workforwhichrhislcnnitiisslcd.Iihrlltu,cmployonyncnninanymrnmrv, as ro trom suhj.rr ro rnc ao*cc conE.sarioo lar\ ol Calirodi,, and rgre rhd if I should h(ioft iubi.r ro ttr
<br />edrtds.ompctr$lion[ovkionsolSsrion]TOOofrh.tf,b.rCdl..Ish,ll.ronhwilhsrPlysirhrE,sPn,visions..
<br />WARNINC: Fnilurc ro {cur wi fl .o pcnsdi('n ovcntc is ufl|.fl'ul. ion \hall suhj.{r .n cl)lpbrr h oininllrMLrids rnd
<br />civil tin$ !p ro one hhdrEd rhoxsrnd d.llrs (Sl0O.O{Xr, in rddiriotr h lhc coi of con+jnsdrio., drnu8cs os prcvidcd lff rh.
<br />Scclion 3l)?6afrh.lrtxrCodc, mrcrc( rnd ormy'\ lit\
<br />*'l.lAY 1? 2018
<br />I hcFby amrn undcr F.alry olFrjury rh0t I am licctrsn rndcr pmvnion oI (:hatrr 9(commncitrE silh Ssrili 7m0) ofDivGiotr l
<br />of lhc Busincs and Pmfcsbns Codc. and fryli.ci$ is in lull 6rcc Dd clttcr.
<br />looqtoa
<br />YrMya
<br />IANiIB!]IIII.)NI!NIUN!;.d!iENII
<br />I hcrchy ufifln undcqannlryofpc.Jurrrhar rhcrc i\ i.on(d.rion Lndin8 ageNy tur rh. l}.rfonnrtuc ofrhc *ork lor chich rhi\ Fhlir ir
<br />issrcd (Scc 3097. Civ C ).
<br />Lrndcfs NrnE
<br />-AIIII(ANTIIESAAAIT!
<br />I ffiy on'm under pcnalr, of pcrju'y om ollh. follo*ins dtrl!rrion\
<br />D.mlirion Pcrnik-Arbcsld Notificliion Fcdcrat R.culalions (Titlc rU. Pd6)
<br />_Rcqui[d kiicr of llorfi dion
<br />lcd,l, ths! rhclcdcrrlrcFul.rioN EBrdins a\bc{"r (m. rl rc nurdml'cahk rolhnlln iN
<br />tlEccn,ry rhar t h.vc rc,d rhis smlr,r'on and {,rc rhsrfic aho!. infomrion t cotrer.l lere ro.omply wnfi allciryad counry
<br />foimircs and Slak L!q\ el,rins h burld'nE conrrdcrrtr ard hercby aulhori^ r.pe.cnl,iiv olihis City !trd Counly lo cnrd ulbn rhc
<br />ftotc nErtiorcd pnpc,ly fir in\pccrion puipoi.\
<br />Vr"^;l,n #rY n7
<br />'010
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Solfit Rouqh
<br />Ceilinos (T-Bar Rouqh)
<br />Meter Release
<br />Rough ,/,rlc 116 uFn\a.
<br />Service lvleler
<br />FINAL t-/?-/9-/*{i4:@
<br />Notes, Remarks, Etc.
<br />Appliunl or Aaent Sianuh'R
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