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ELECTRICAL.INSPECTOR FECORD
<br />APPBOVALS DATE ID/SIG.COMMENTS O\f,NDR AUILDER DELCA'IATION
<br />I lrr.by affinn undfi l).nnlly or pcrjury lh,l I un.r.'nrr rmm rhc OontndoN Liccnsc Low for th. aollolin8 rcosn (Scc.70ll.5
<br />Bu\incs lnd Pmacsion Codc) Any City or Counry which requncs ! rrfi to anirtucr. alr.r intbvc, &mlirh or e|Eir My
<br />irucrxrc. lritr ro ns issud.c. al$ r.qrircs rhc rppli.a fd soch Fmi b filc 0 sigmd {atmd rnar $ or shc k liccnscd lu6unnl
<br />ro rhc pmvisions ofrtE Conrracrols Lienscd L,w (Chlprcr 9. Comncn.ins wirh sc.ri.n 7(xD or Divhion I oi lhc Busincs .nd
<br />Pn,r.sionrCodc)orrhdr h.orlhc i\.xcmfl lh.rcrtum,nd rhcb,sis ror rhcalkgcdcxctrrplion. Anyviohrio.otScclionT0:ll.5byuny
<br />rynlica.l l'or a pcmir subicrslnc opplicanl ro acivill)cnrlryolnol mrclhlnfivc hldrcd douus ( S5fir).
<br />l.nlowi.rofrhcpi{,Il€ny.ornycDk,y.cswirhql8cr,srh.ne,h.oDcnsdi(nlwilldorhcwolk dthcnmlurchnol
<br />i cnd.{ oroflcod f.r slc lS(.7O4i. Busin.ss.nd Pr.fcs\nns Crlc: Thc Confulols Li.cnsc Lrg docs nor lPpl! ro an osnc, of
<br />rhc p^jpcrry wh. burlls or impnr$ thcNn. dNhodocsnrchwo*hirnsrllothcrcllorrhrour[hisorlrcrowncntfl.y.cs.
<br />pnrlido(lrlEr such inrn{cmnkmnor inrc cdoroflcnlfor{k lll h.wNcirh. huiklnEor i'qrovcnEnr is lnduirhin.R }$r
<br />otcorll)trriD, rhc Owrcr Buildcr *ill h,vc rhc hordcn ol prorill8 rhar hc or dr did nor hild or inpn^t th. p6Fny for rtr NlIs of
<br />1.,\ownerorrh.rn,prny,an.rclulivcltconr ii.s sirh liccnscd .onkrrDs tu cln{rud lhc pmFlt (Scc.7014.lrusins\
<br />a hof.$ion Codcr ThcConlloctor\ Liccnsc Liw des mr0rDlyto ano*ncr.fpmncny*h() huildror imnrovcs rhcron.
<br />,.d slr,.omn!\forru.hlrojdswkh,Conrtucbnnli.cn*dpurxanrrorhc(tntmctolsLienscku).
<br />I amcrcn{r undcr Sdion-. B. & P.C. forlht rcasn
<br />D.t€: O*mr:
<br />rvoaK[&r:rl)ufENs .rIaN
<br />DIICII.SAIIQN
<br />I hcrcby{flrfl utrdcrr.D.ltyolrEpryoncollhclt k)*in!d..Lrrriotrs
<br />-lnavcalnwillmi
<br />ainoCcrrifEatcotConsenrroSclf.ltrsu,clirwo cn'conr.nsdn,n, a\ I,6!idcd for by sc.rbn l70oorrh.
<br />trbor Oric. t r rh. pdformm. oi rh. work for whi.h lhc l.rmn is ksucd
<br />I h,vc rnd willmrinrlin workcrl compcnsotion in{mncc, as rcquncd hySccrion]?mofrhc ljborG)dc. r(r rhc rrfomtmc or
<br />rhrtroal,rtrl\hrh\Frfnrr:s\uAlMtr.r[.h.un'!.r\.'rnn '.udrccdtr'crdrdr,lr\ nutrjn scM
<br />,,,,,",,,,,',*, - 0OO 1-o\ ES\- b \r l3\ ltK
<br />-l
<br />cc'1ity rhll in lhc pcllhinume oirhc *ort ror qhich rhis ll.nnir i\ i\socd. I \hall tr l.nlloy 8try I'.rctr in my motrncr
<br />v,ark,h.conx\ubj.r!rorh.vorkcB.omp.n{rn,nh*rorcahft,nria. d,8rc rharifI \hould bNom suhjcd rorhc
<br />soikcrj.o,npcn{tionF)vhionsols(tiotr3T0ooflhctihorcodc.lshrll.ionhwilficonDly*irhrho$provht,ns.
<br />W RIiIN(;: fiilurc t) Rcurc workr^ conrFc srri(,,is rihwlul. nnd shrll suhlc.l rn cmploycr lo crinrirl pcnrllics 3trd
<br />rNil fiDcs trp (' onc hun rc.i rhot\rfd dol
<br />s{ltjl, .ll)76 orrhc trhtr C{xlo. inrcrci rnd
<br />(st rddirtr)n k) rlr .o{ of.(d,mPcs rr rrovidcd lor rhc
<br />I hercbyallirn' undcr pcnrltyolpcrjury lhar I am liftnrn under Fovnion otCh+rcr I (.onrmn.ing wnh sdrion 7fiJor orDivhion 3
<br />of lhc Businc$ and Pmf.ssiorN Codc. and nry licene n in tull lorc aM .lf6l
<br />I .-]t)l0D k"tD
<br />6ltK lc\ \2.^a
<br />IONSIBUqUONIIXDINIj.AAEN(I
<br />I hcnby 0n.rnu crFnnnyofpcrjuryllurrhcrcis{con(flclionhmlin8ascrc}rnrhcrdr.nruNcorrh.workforqnichlhnFrnilh
<br />issu.d (Sr. lIP7. Crv. C.)
<br />AIILIIANLOICIITBAIION
<br />I hdrhyrffimutuLr Fndlr, ofp.rjury one ofrhc follosing dc.l- ions
<br />Dcnmlirioo Permih Asbcsros Norifrarn,n Fcd.ral RcEularions (Tirle40. PM6r
<br />-Rcquncd
<br />lluer of l'lorifi clrio!
<br />I ccnilyrhnr rh.Ic{lcrrl rcgtrlario s rcaartlr! a\h.d.\ rcnn,hlrR iorn0tli.nhlc t, rhn |h,t cr
<br />I rcnilyrh,, h!. r.ttrlrh,\ rfi)li.aroia e crh rhcxh)vc itrhnfrtriotr tcorccr I {sre rommply wirn aU Cny ud counry
<br />onl,dri(\ nid srrlc Lns\ rclnrid3r, burldirN slru.ini. atul hc,cby {urlntri^trurivcs olrhis Ciry lnd Couryio d rr r|rn rhc
<br />rbvc m rioncd nr)Ii.nt fn in\
<br />A|)',li$nt trr ABut liiI."1',
<br />Nquqqn
<br />bll'{
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding i UFER qNtua'
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Solfit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />Roush ]'m 2-\l'1"x,uil['
<br />Service ltrleter t)
<br />),\1f,1(- ---J--vNotes, Remarks Etc
<br />I
<br />'7-71-1"'
<br />Ivleter Release
<br />FINAL
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