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ELECTRICAL-INSPECTOR RECORD
<br />APPBOVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I tcrcl,y affi, undcr pcnrlry ('f perrury rhd I m ercmpr fmn rhc Conrr0croF Li.i{ l.aw f(tr
<br />'h.
<br />follouing B,$n (Se 70ll.5
<br />Ausiri.s ,nd Pr.f.sion Codc)r Any Cny o. Cou.iy qhi.h ftqrncs s p$nln lo c.nsru.r. all.r. imp.ovc. dcmohh or rcptrn ony
<br />srru.ruE. pturrn ns hsuoncc- al$ rc.ruircs th..ptlic0nr forsu.h lErmi ro fika si8trcd sraremnr rh.r hco! shc n licen{d pusuanr
<br />lo rhc lorisions ol llr conracttr s Lic.nsd bw (Chaprdi 9. Comnrn.ing w h scctiotr 7m0 ol Division 3 ollhc Businc\s lnd
<br />Protc$bnsG c)orrhlt hcorshc hcxcnpr rhercfron ond rhc blsK n,rh€ llle3cd eicmrrion Anyviol,rion.tS*rion70.1L5byrny
<br />aplli.anr foi 6tci,nir lubjfttsrhc 0ptlicrnr ro acivilr..dlryofnor fltrcrhrn fivc hundrcd dolltrs l$50O)
<br />-1.
<br />as owmr of rhc lt,otcny. or my cmployes tr irh * oaes .s rhcn $t ompcnsrlion. * ill do lhc wort a,n rhc {dm is nor
<br />inl.nd.d orofrdrcdfitr*clsd70l.il.Busincssndti,lcssioisCdle IhcG)ntacrtrrLi..n{tiwddrnotrrplyto!trownerol
<br />rhc rmlf,dy lho buikls or Lnfl ow. rtENn. {xl who JrEs skh wo* himlcll or hc clfor rhmu8h hi\orhcrosncmplorccs.
<br />lnrvidcd rhd luch i'npmvc'tuih dc nor int.ndcd oron'crcJ fff strL ll lx,wcv.r,rhcbuiltlingor i'npmkntnr hsoklwirhi'r',nc rrrr
<br />.fconphrion. rltOwE Buildcr *ill hrt rfu htd.n o, pmving rhd tE or sir dil nor huil. Dr nqr)t rh. pDlf,nr rbr rh. lu]1t's of
<br />-1.asosn
<br />rorrhcpmp.ny.r cx.lusivcly coMr.lr8 wi'h liccns.d..ntr.ldslo.on(rucr rlr pmjccl (Sa.7044, Bu5i"c$
<br />a{l t\trlNin Codc: Thc Conlrlcrois Licensc L.w does not apnlyro M owner of nropcny *h() build\ o, inpn,lcs rhcr..n.
<br />,nd who..nhchrorsu.htrclc.kwirh.Cuntick'(\)licorcdtur\Mnrk,rh.Contr.rofrLicutrrtiw)
<br />r0a5l8s.(!utENsArQ!
<br />DECI,I.BATION
<br />I hcrcbydiir undcr Fmxyort'.rjxryotrc oirh. lblbwnrs dccldario.\:
<br />I havd ui will rtuinrsin u (tdifi.arc of Con\clr ro Sclf lnsurc f{tr N.rtc^ NmFn$rion. d{ tmvid.d for by S(rion ]70O of Ihc
<br />ljbor Codc. fff lhc DcrlornEncc o f l hc *ort to, Bhich rhc n flnir is issucd.
<br />-!3t'.' " ""a *' rr "'.,,"r"," *"rlch' romFnsrr
<br />'otr 'n{rrNc. as rcquncd by sNr ion .uO0 oi lhc Lohor Codc- tor rhc pcdorrucc of
<br />-rhc trorl ln, rhf,h r[h r{mut I rtud My trorlch cnmn nsrFn msurrR(JnEr orn polf,} nunrns oc
<br />,.",", Fu+, s lnsr-.F|,p-- sCtr'Sr..+! Vr,
<br />"",.,n"^*,,'{L)l ezz/}L1b,,,.,,"" /2// q,/za/V
<br />I ftnifr rhnr in rh. F f(,@r€of
<br />'he
<br />wu* ror uhichrhh p€mir is irsu.d,I \hnll noi.npl,)y a.r lx6on in rny aurncr
<br />e s lo bccom subjccl to lh. wortql onrpcnsalion hqs or Cnliloir a. {nd a8rcc lh.t if I should b..om subi$ b
<br />'hcwor kdj .omrc.sation pmvisions of Scdion l?m ol thc ljhr c-odc. I shdl. fonh$ nh mmply anh ttur pmvhions..
<br />WARNING: Foilurc lo sclre sorkcn onrrcnsarion ovcmsc is unl0wful- lnd shall suhFcr !. c.rl.rr ro di. n0lpcfl0lrtr and
<br />ci\il finc\ un h om hDndrcd rhouisnd dollu\ rllfiruur). in addirton lo rhc c.d orc.mF.q'ion, damgcs as pr.vid..l ro. rh.
<br />seri,'n 1076orrhc ljrk{ C,ilc.jr.rc{ .tu1 drqml re\
<br />*,*,. i/tiZy:X,. -Z-_
<br />, LICFNSE'C(INTAACTOR
<br />DECI.AaA.II!}!
<br />I hcrchy lmrmuodcr pemlty of pcrjury rhar I am liccnsn undcr pmvGiofl ofChryrs 9 (contunci.g wirh Sccrirn 7l0o) orDivhi.n I
<br />ol lhc Busincss and Profc$ions Codc. atrd myli.cn$ is in tuU roNe ciEif
<br />6z czo
<br /><-r?
<br />l!Dt.lt!]]!ltotLr!ua.a.l1r!1!
<br />I h.Fby aflnn, undcr rcn rrofpcruryrh, hscissc.ndddionkndinga8cncyr(trrhctdfonMn..ofrhc*or*lor{hichlhislctmilis
<br />i\sucd (scc .109?. Civ C.).
<br />Lndcls Nanrc
<br />-
<br />L€trdcls Addtcsl
<br />l.c,rilirh rlr rcddnl rcgtrldlbtrs a8rd$9 ,\h-noi c bvnlrc tror rt)flicihlc lo rhLs D.ojsr
<br />-l
<br />cea iti rhlr I havc Ead rhis lptlicrr ion end (urc rhar rhe ohovc inrb@r ion is .oml I +m ro .omply wilh lll City and Coutrly
<br />r'l'n,fr.\ nnJ Srsrc L!tr.(bringt,, huiBing .nn{ rud i.'n. sril hc(hy,urhnirc 'rFr*nrar'w\.1rhr C yJndCounrlr.cnrs up.tr rhe
<br />:H:,:H;::"I '"F- ..,"t/,'/{
<br />". u*", .,on^u,z''[4a 77r>24-S
<br />Underground
<br />Pole Bases
<br />Li ght Standards
<br />Spas, Pool, Fountains
<br />S igns (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueing
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilin gs (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rough)
<br />I\ileler Release
<br />Rough
<br />Service I\/eter /a\
<br />FINAL f"-n-/f VWIU,l
<br />Notes Remarks Etc
<br />Site-Work
<br />Sub-Panels
<br />l. ncx. rI undcr Sc.r($ .ll & P(' l,trf is rrror
<br />lhlc ()*n.r
<br />AIILrcANLIECIAf,AIIO!
<br />I hot+y allm undcr penalt, of Dcrjdry o( of rtc followin8 dalaEt ioos:
<br />Dcnolirion Pcrnrih'Asbcsros Norificorion FedcrilRc8ulationsCritk rl0, Pon6)
<br />-R€quircd
<br />Lcltcr of Norificalion
<br />tt
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