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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />L ight Standards
<br />Spas, Pool, Fountains
<br />Si gns (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Siab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rouqh)
<br />Rough
<br />Service lvleter A
<br />FINAL q+l-lv x\?bd
<br />Notes, Remarks, Etc
<br />OWNER BUILDER DELCARNTTON
<br />I hcrchy ofinm undq !.nrlry of pcrjury rhar I m cicmpr l',onr rhc Conir&rB Li.cn\d Law ror
<br />'hc
<br />hllowin8 rc6$n (5(.?0:11.5
<br />B!\incss aad Pmtc\snrn Codd) Any Ciry or C.Dnry *hich reqxn.s d F.mn lo condrucl. ultcr, inwovc. dcnunnh or rcprn any
<br />{tucruc. prior ro ns i\sNn.., al$ mqun ! rhc,r'dicanl lnriuch Frnrii to filca siBncd shtcmnl rhut hcor she h li.entd pu^uanr
<br />ro rhc tmvnions ofrh. Contmcrols Liccnsd L{w (Choprcr s, Commencin8 *irh Scc'i.i 700(, ot Division 3 ofrhe Busi.css and
<br />Pmfc$ions Codc)orrhrl hcorshc ncxcmpl rhcrcimm ond rhcb(sis forlhcdlLgedcxcn9rk,n Anyvirarn,nofSslhn?0l,5byBny
<br />lppli.a tq r pernir subjcch rhc rptli.anr ro a civil Fnalry oa oor mn lhm nv. hundrcd dollus (S5OO)
<br />-1.
<br />{s ow.crofrhc pmFnt. ornr, cn,rnry$\ wiih slscs as rh.ir qnc.onll.isnotr. willdo lhc wo nndlhcslnrl!rcnnor
<br />i'ncndcd orol|rcd nn sh (Sa 7044, Au\incss. dPmf.sionsCodc:1hcC:onracnnsLiccnsct wdocsnollpDlyu,nuwn.ror
<br />rlDl]n)Nny who huilds or iryrcrcs rhcNn. und sho des srh *ork hir$ll'or h.r.laor rhrolsh his or hcr ow..nplolccs.
<br />pmvidcd ihar \uch improrrmnh N mr inrcrd or oliscd tor eh lt ho$cv6. rnc hiklin8 or improwftnr is $ld withir .trc )car
<br />otonl,hlion. tlEOw.cr Auilcr willh.k ihc bunlcn ofpu)vin8 rnlr hc o! stc di{l mr 6{itl or i'ryrov. rhc pRlp.nt for rhc ptrrp.{of
<br />_1. xsowncrolrhc pmpcny. rdcr.lusirclr.ontr.rinB wirh li.cn*d.onrrnns n) o.(dd lhc proirr (SE. 7044, 8u'i'tr$
<br />.nd Pioi*sirn Codc rhcContr.croisl,iccnscljvdmsmliftlytorno*ncrolpn,pcnyNhobuild\orimpblcsrhcrcon.
<br />rnd trho cont&rr lnr srrh pni..r\$ th (irturnnrn lircn\.(l puhumr !r rhc Conr.croiF Liccn$ ljw)
<br />;:i424{
<br />I hcrcby.liirn undcr rnolly ol p.rjurione of rhc
<br />I havc dd sill mdinriin a ccniaRarc ul cron*nr ro scr.lnurc f(r so.kc6 co.rrEnsdi,)n- as providc! nn bys..rion l?uloirh.
<br />Lf,bor Gdc. lor rhc Frfortunc. of rh. work for shkh I hc p.nnir ir i\su.d
<br />I hrvc rnd sillninrlni. qorkcrt co,nD.nsolbn insurancc. as rcquircd hySccrion lTO0ofrhc LihorCodc. for rhc tcrlornma ol
<br />rhc work l'or wnich Iht Frflrit is nsuct. My worter' omlcnsal ion insuraneoricra F,li.y n!'hbfi dcl
<br />-l
<br />ccnily rh.r in rlE lcrLrnBrce oirh. wo* ior *hich rhk F(nir is i\srcd. I shrlr ml cmploy ony pcrwn in rny mdnc.
<br />$ .r ro lr.o'E subi.r lo rh. workcs conrD.nsornr hwsorcalirornir. ond o8re rhll if I should bcoft \ubj.d ro rrE
<br />ro*cs conr!.nsariotr lrovisionrolSsrion l?(xl ofrhc litnr Codc- I shall.,onh*irh omPly *irh rk,s PovisntE..
<br />WARNING: F{ilurc ro s-.'urc workcri.ompcnsdion o is unllwftrl. m{l shrll subAr .n cmpk,ts ro qimiml pculri.i and
<br />.ivil lincs uf b oN hundrcd lhousand dollar (S r of.onlrnsarn{, drnrgcs !s prolidc{l for rhc
<br />Or,", q:i 7 tv
<br />I hcrcby rltm undcr pcMhyol|trjur,(nr of('hrtrcr 9lc.nnncncirB uirh S.cri 7(xX)) or Dn i\i,r :l
<br />LMn( Numho:
<br />-
<br />Corlriclu.:
<br />CONEIf,IJCIIIINIENDA$IGENCI
<br />I hcFhy amrn, undcr rsDlry of p.rjury thrr lhm h r co6 dd!,. lcndinS aScncy for rhc ,qfotucc ot rhe utrk for which rhh ,qmil k
<br />hsucd (S(. 1097, Civ. C.).
<br />ATfLTIANI.DECLAMIION
<br />I tsEry lrm onder Fnllry .l perjury o* of lhc rollowing dcclsal ions
<br />Dcmlirion Pcrmik'Ashc(os Notificlri,n F.dcdl Rc3rlarioni (Tirlc.10, Pan6)
<br />-R.!uircd
<br />t lrcrof Notiarcarhn
<br />irharrhc lcd.rrlrguhrdN r.rrdin8ast {.srcnmvrl0rc nol aapliuhlc ro rhhprojc.i
<br />yth,i lhrvc rc.d rhisrffli.rrionaftl narcrhnr rhc,tnrc inri,nrori{,. i\con cr IrgrLrrocomplrwilh!llCirrrndCounr,
<br />snnd Shrc L'wsrchtins b hlildin8 conntucrion. uxl hcrchr_atrhorir.rcprcscnrdNcsoilhiCiryrnd Cou.ryh c rcru|rnlh.
<br />n rd ablf,ny rir ir\lxctior
<br />,,,,f ,nn,,,
<br />.(o> Cr.a- ,",. ,l(zs\td
<br />I
<br />Meter Release
<br />td
<br />.l rl* Bu\ircssand Pr. icssio n s Codc. lnd nry liccnsc h ir lnll Inra rndcffccr
<br />Gndcr's Addrc$'-
<br />T
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