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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDER DEI,CARATION
<br />I hcrcby rrarn und.r p.nalry or rcrjury rhar t dr crcopr ft,nr rlE cont,.k,n Li.ctr$ ltrw ror lhc lollorinS rc.{',n (Scc.70ll.5
<br />Businc$ md Profcssion Codc): Any Cil, or Cou.ly whih rcquncs 0 pcrmil ro con(rucl- aircr. iryrorc. &mlnh or rcn, r rn,
<br />ocrurr, prior b irs hslMcc. rl$ rcqun \ rh.,ppltd tu \uch lErhir t,liLn ii8 cd narcmm rhlr h.orfi. is liansci pu6u0nr
<br />ro lhc pmvhions ot thc Co racrnr'r Licen*d Li* (Chaprcr 9. Conmcrcins wiln S.crn,n 7(ljo oa Divixion I orrht Busnt$,trd
<br />Pan.sqt,ns C.d.) or rhdr t*orshd i(cxcnp hcrcfio mdrhchbsi\lbrrhcallcgddcrcnrrlion.AtryliollliotrolSdbn?0ll5byrny
<br />irpli..nr lor 0 Fmi suhj(r rh4 aptlic0trr to 0 civil Fnrhy of nor rcrc rh.n nvc hundrcn doll$ (S500)
<br />ll. r\ osn.r of rhc pn,Fdr", or ity cntpk,y.r\ sirh srrc\ r\ rhcn s)E co r$ \rrn,n. * ill du rtr *hlk Md th. n ndu!- r\ nor
<br />i cndcd or ufi.rcd tur \ c (Sc.70,1-1. Busirc* rnd Pn)fcs16ns Cu c Th. (in*i.tx s Lic.n{ tiw docs mr anlly lo raowrr o{
<br />rhcl^,p.rry *ho huikls or nryotls ltENn. afrl who dNs {Eh qrrk hms.li.r hcr*llor rhmugh hn or hcr osn.nrplol&\,
<br />m)vidcd rhnr nkh inrpR,!.nrnknrc n.ri'n.'ylcd.ron'cRl lbr {lc Ir.lar*crcr, rhc huildnE or i'npnnmrcni i\ s) wirhi1oN}r,tr
<br />ofcon1l)Lri,n. rhcOsrcr Bui}ilcr eill hnk rhc budcn olprorin3 ihf,i hc or \hc dil tror buikl or inpmvc rhc pmFiy ftn rhc I,UqxN or
<br />,{5--. "**, r,* a"*y. dmcx.lusNcl, conrhcrin! wirh licenrd conra.tuR ro $nifld rlE pmi{ (s.c. ?u4. ausimss1-?f a"ts'i,, c,'.r" iil c.1",*.,'' u"""* r"" o.!. "or.pplr ro anoqncr orpropcny sho l,uiids ". impr"vc" rhcicon.
<br />and who co.lmcn ror sudh pmjeB wnh a O E.k (g li.cn*d lunurnr ro rh. co ftcrorsLd.scljf,)
<br />I rnrc\cmnrrndcr Sdln
<br />,",".&//tf r ( "***
<br />OECLIEAIIIIN
<br />I hcrchy a nn undq ,En.hy ol lx ju,y om ol rhc lolk,wina dcclarurn,trs
<br />-lhavcandsillnuinrainaC€niarareo,Cons
<br />ro Scll lnsur. f{tr workcs conEo\lrion. N p,oeided ror by s&rn l70o.rrh.
<br />Llhor Codc. lbr rhc !c omtuc ol rhc work for which rhc prmil is hsucd
<br />-l
<br />hrlc rnd sill'nri din worker'cofllpcnsdlinn insurnnce. !s requncd hySccrion 17006frhe ljb.rG)dc. f* lh. Fnirrturn.c or
<br />rh.workInrwhkhlhispcrlnnisissucn.Myu,oricrs.omlcnslrio.iNuratrcccrricr.ftlp.licynumbcruc
<br />,.$(*n'ry m, i",r." p",ri.rtrun(c nr,hc {o* l.' whtrhthhpcnnir is nsucd.lshrll nor c,nrloy ony peson in lnymrtrncr
<br />-i,,f\ ro hccnm \ut cd h rhc *orlcn .nmFnsrriir la*s olCdirorni( lnd lsN rtar irl sh.lld lrcom.ubj.cr k, rh.
<br />s.rlc^ conrpcn\ari,r pnivi\ions ol Scdn,n.l7(xJolrhr I rhtr Co,lc.l shrll. nfihBirI conplt wirh rlr\c pn'!ni(i rs
<br />WARNINC: Irxilu'r b \cru( (orkrr\ .o'nprtr\rli{n, corrrrc hiccr trn flnpk)yor io di'nnril Nmtr\ rtrd
<br />.ivil fitrc\ up t' otr. hundftd rhot$nd dollrr\ lsllx)-(xr(). in dir .dN of.onp.nsrnrn. drrog.r rs [ovided lor rh.
<br />::::"'." :"' ^
<br />iilrJTi i"" ""
<br />npXerr:X\
<br />DEIIAAAIIo!
<br />I hcrchy afirm undcr Fnallyoip.riurylhat I om liena.d undcr rrovllion ofChaplc.9 (commncins wilh Setion 7000) orDivhio.l
<br />of lhc Businc$ and Ptua.$ions Codc, rfll myli..nsc h in rullr(tr. d.fidr.
<br />IONIIIIUCUOI{!INIIINCrIIjENCI
<br />I h.Eb, dmr und$ Fmlry ot p.r.iuiy rhr rh.rc is a snnrocrion lc.ding ,gck, 16r rhc lxriormm of rh. wort for whicn tht Fmil G
<br />hsucd (Sec 3097. Cir. C.).
<br />A.TEII(3!fDECI.ABAII!}N
<br />I h.rctry lnlhn undcr Fnalr, orFrjury oft orrhc rollowing declda'iony
<br />Dcnbhbtr Pcnic-Asbcsros Noriricrrion F.ncrcl Re3llarions (Tirlc 40, Pan6)
<br />-R.quied
<br />l,rrcr of Norifi uiioo
<br />l.cnilyrhrr rhcltd$rl'c8nl ions rctedi|8 dshno(tonn)lrl c.or tpl'.rhlc ro rhn!tutc.r
<br />k,ll,,ll l,nr.ill,'"r,,rx
<br />ah^c nrc rn)nrd pn,lcnt lnr i,\pcdnn,
<br />nrr,,."n, ", n*.n, a,*nr"." X=
<br />O--r*--*'Onr,,( f
<br />rlr dh,!c irlonr(i(!r is.
<br />Ir c fi-C ?. aats^
<br />ro conDly *irh all Ciry rnd Couf ry"':,':.':"';i,{il"
<br />Sile-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Founlains
<br />Siqns (monument)
<br />Life Safety /Low Voltaqe
<br />F ire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soflit Rouqh
<br />Ceilin gs (T-Bar Rough)
<br />Meter Release eu6lt$ *.\.arb t '45.4N
<br />Rough
<br />Service l\/leter I I
<br />FINAL 'l p\tb .z4Z-//4b)
<br />Noles Remarks Etc.I
<br />- \ rtr-,-2. c ? 'Drl,4- .J)-v-:-
<br />Under Slab / Floor
<br />Liccnsc Clas
<br />-Li.cnsc
<br />Numbcr
<br />-
<br />Da(q Conlrr.rorl
<br />L.nde r Addrc$.
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