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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG COMMENTS OWNER'M
<br />I hcr.by.ll]rn uM.r |f.,lry orNrjurt rh,r I m cxcmfl no'n rh. G,h.don Li.ctrsc l-aw ror Ihc follorinS rc0str (S(.?0ll5
<br />Businc{s lnd Pnlssion Codc): Any Cir, or C.unry shlch rcquircs 0 pcrnrir b cotr{rucr- rlrcr. imprcvc. d.nn,lish or r.pan any
<br />nrucrurc. p'i(trk, i( irsran c. d$ r.quirs rhc lPlli.rnr for such Frmir n, tiLn si8trcd sarcnfft rh.t hcor shc is li.cnsed purHlri
<br />t, rhc Dmvhiins ol lhc Conlrucr{n s Liccned l-rw lchaptcr 9. Connnercins wilh Scdnrn 70(]t1 oa Divni :r orrh Businc$ ntrd
<br />Pmf.siohc Cod.) or rh, h..r sh. i! crc'pr rh.rdfrom rnd rhc ha\i\ f{tr rhc rllcgcd cxcmflion Atry violariotrofS(tion?0115 hy trtry
<br />.Ipli.ad for apcnnn suhjNc rhc +tli.n to r.ivilFn,lryotnornnmrh,n,lv. hu nddollrs($5m)
<br />-1.
<br />!s owner of lhc pmtEny- or my cmployccs $ilh wr8.s as in.n sok on{cnsation. will do rhc sork 0.d lhc stur& i\ nor
<br />intcnlcd oroficrcd for solc (Str 7044. Busines lnd Prcfession\ Codc fhc Conrrlcrols l,kcnE li* dNs nor ryply ro sn own.r of
<br />rhcpnlxny who build\ or inpdvcs rlrc)n. unwho &rs srh so* hifrsclror h.r*lforthnru8h hh or h.. oqn cmplorccs.
<br />povidcJ thar \uch impmhmnrs rc fln inr.ndcd or on'cftd Ior eL ll howcw, rtr huililiry or irpn,vcnrnr itr $Ll wirhin .rtr ,trr
<br />olcotrlllklion. tlE Ow.cr Buitcr will harc rhe t{.dctr oiirmvinS ih.r hc or shc dil mr buiH or impnE lhc rmrf,n, fd rhc pqr'€or
<br />I. r\o*ncrolrhclopetjt rmerclrsivcly.onrracring wnh liccnscd contrckns h cointuct rh Ifiicr (Scc 7(Il-1, Busnc\\
<br />n*l Iri!,fl\si CoddrThcContrcttrsLiccn\cLrwdorsnorrppl,t,nnown$ofponnywh.huild{ornnpmvc\rtcrcotr.
<br />n.d who .ontlct l'or {rh pnrc.k sirh r C.nrBcri)n n li.cnscd ptr^u hrhcGnnrncttr \ l.i.cn\c l.trq)
<br />lr'ncrcn, utrJrr Sccrnr .B &PC turrhi\rc n,r
<br />UABKEBS_COMIENSAIIoIT
<br />PECLABAIIQIi
<br />I hcrchy afllrm under pcnally ol Frjury one orrhe tollowing de.lrllion\:
<br />-l
<br />halc ad uill nEinlain a Ccnifrarc ol Concnr ro Sclf lnsurc for worksr colnposlrion. as pneidcd f(r by s(rion :lTlD ol th.
<br />tjh.r Codc, fo! rhc pdforroRc ofrh. wo* ior whth rh. pc.mi k nsu.d
<br />I hAr rnd *ill mainlrin worker' conFnsrrt,n insurancc. !\ rcqutcd hy Sccrin l XXl of rhc lrhor c()dc. fd rh- t{rfonMmu or
<br />rlf qork lor *hth rhi\ pcrnril is h\ud My*or\c6 conrFnsalbn insurrncc .rrir rxl rx,licy nunrh.r nrc
<br />l.cnify rhnr nr th. p.rformncc ofrhc qork fo. whi.h rhi\ r.rnir is i\sx.d. I slull nor cn{loy rny lcnon in any mo*r
<br />{, !\ b hcom sul,jcr l{, ric workqi .on\Tnsal ion laws olcxlifo.niL rnd alrcc rhd irl shoxld tE..m subj.tl ro ttE
<br />w.rlc^.oq,cnqri,,npmvi\nrn{6fSftrion:1700.frhclf,ho.Codc-l\hnl!.fonh*irho'npl!wirhrhospmvsions..
<br />WARNINC Faihrc ro $cm @rtc^' compensarion covcmBc t unlawtul. md sh,ll slbjcr an cnploylr tu dimn,ll lEmlri6 and
<br />civil 6ncs up to om hundrcd thousand doll&s (Sloo.(xrcr. rn iddriotr rn rh. .on or.omntt\artrr. 'lstuEc\ ti Pr.vid.d f.r rh.
<br />Scrion l0,6orrhctib Code, inrcrc{ and a orrcy.lccs " t ,/\ I
<br />,,,., 5.1 D' I A _ ***lrfu4 y-/,"d 0'>-
<br />LICDNSFD t{NTRACTI,R
<br />DECIdAAIIQN
<br />I hcrb, bmrm und.r pcnahy oa p.rJtrry rhar I m licnr.d undd F{,!hio. ot Ch,pt.! 9 (..mmncin8 wnh Sdiofl ?(x)0) of Dilhion :l
<br />of thc Busircss otrd Pmtcssions Cod.- and my liccn$ G in tull forcc aDd cffd
<br />AOXEINIqUOIIENDAC.AG
<br />I h.rb, arum und.r FnNlry of t,njury thar lh.rc i{ a .on{ru.rirn hnding r8cmt aor llE lcrfornEtre ol thc uolk nr which rhi\ Frmir h
<br />hsucd (Scc 1097.Civ. C ).
<br />ATILI'3]ILIIEqdAAIIAN
<br />I hcdry rnm und.r Fnolty ofl€rjuy oft of lhc iollowlng d.cldarn,ns:
<br />Demolirion Pemrih Ash€sros Norificalioi Federal Rcslllrions (Tirlc40, P!n6)
<br />-Requned
<br />kncr otNorifi cadon
<br />l.cniltrh r rhclLdcrl'cgulnr'urs r.!ddnigasl{nosrcntr,! lrrc nrrrpt,ln t t) rhi\ frrrtc.r.
<br />l.Lniftihr l hr\c r.rd thn lpflicalionand strl harthcat vc irlonnltion n
<br />ordirrtr.cs dd Surc Lass r.ldritr8 ro buitnr8 co.srudnrr
<br />agre ro comply wirn sllCiry,nd C.unty
<br />ivcsnlrhnCnyandC,,unrJt,cntrr F)lrhc
<br />,,,, t t&lb
<br />Site-Work
<br />Underground
<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 / Groundinq / UFER
<br />Translormers
<br />To uerng
<br />Sub-Panels
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />Ivleler Release
<br />Rou gh
<br />Service Ir,4eter
<br />FINAL
<br />Notes , Remarks, Etc
<br />Pole Bases
<br />Air Conditioners Policy Numh.r: jpi,es:
<br />-
<br />trndcr'. Addr.s
<br />rh)vr nrtrritfrr L |Irr,1y rar
<br />Applica orAllenlSignalur 1
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