|
ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE IDiSIG.COMMENTS
<br />Sile-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Salety /Low Vollaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER lozl-tg 4*nn ,nz)
<br />Transformers
<br />Torqueino /o.Zfa6 Zezl S*G l4"JL d'&L
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rouqh)
<br />It/eter Release D2q-/9 Zz-'t
<br />Rouqh tD-il-t 9 ('-zaa
<br />Service lvleter
<br />FINAL /z-34 B z7c2-)a,- A.-J
<br />Notes Remarks, Etc.,/Z
<br />OWNER BUILDER DELCARATION
<br />I hcehy atftrm u.d.r p.nrlry of p.lury lhir I dn cicfrpr fnrF rhc conracrtra Li.coc bw lor rnc follo{inE rco$n (S( ?0:ll J
<br />Busincss atrd Proltssiotr Codel Atry City or C.unly shich rcqutcs a Fm i ro on(tu.r, nlr6, inprov.. d. nlish or Eton rtry
<br />xrtudur. prior ro ns hsuune. aho rcqun.r rtu lrDlic! lu ru.h rE ni ro nh r siBkd rlllcmnl lhll h. or shc is li.enscd poro r
<br />h rhc F)visionc of tlx Co relor's Liccnscd Las (Chanlcr 9. Coarmncins wirh Scclioo ?Un of Divi*i6n I ofrhc Ausin.s nnd
<br />Pmra$ions Codc) or thlr hc or shc h cxcmfl rhc,ctrom and rh. ha\h n, rhc aucscd cx.ip'nrn. Any vnnrlion ofSccliotr 7011.5 hy lny
<br />aprlicanr fu !rEmn $bjccc rh. atpli.m( b r.ivilpcmllyornor d,rrh.n nvc hundrcd dollaB (5500).
<br />-1.
<br />N owncr ofthc lr(,lEny. or ary cnDloyes wilh B0scs !s thcn st compctrsrion, will d. rhc wor* alld rhc $nmm k mt
<br />inr. "ld.rolTcbdforslc(s*.T044.BusircssandPr.f.rsion.CodcrTh.contnctolsLiccnscLowdocsnorlpplyromo*Erofrh. pmrEny wk htrilds or inrpmres thercn. d who dms such wo hinsclforhcNclr.rrhFrshhhorhcrown.n,hyccs.
<br />providcd rhar such im!.ormoh e mr iored.i oroftrcn fo! $k lt- ho*cvd. rhc hiildinBor impmrnE k sld wilhin onc )ear
<br />ol (nvhlion. rlE owEr auilcr Bill narc rnc hudo of pmviq rhlt hc nr sh. dA !d build or irymvc l]rc pDrEiy ror rh. purln$ or
<br />q(
<br />^,,**' ",* n-n"nr, -rc(lui\clr.orracrnA s h lr.cn{d cnnrrccrn" tn en.lrud r hc Fn { (\.. 7o4:l. Bu(m\
<br />lod Eofssion Codc:'Ihc Conrrocrors l-iccnsc Llq dms nol ll,ply ro on o*ncr ofrtup.ny *ho builds or imrovcs thcrcon,
<br />rnd who.o.rfl.krorsuchpma{tswirhaConrndon9lic.nsd!,u6uunrtorheContracrolsLiccnselj{)
<br />I amcxcmpr undcr Scclio
<br />Orer
<br />!l)4(E&l-ra!lfrNsA.rloN
<br />DICLABTIION
<br />t hcrchy nftnn:und.r nMrhy of perjury onc olrhc follo{irg dccla.rrions:
<br />-l
<br />hlvc und sillrMinrrinaCcnificarcofConsetrrro Sclf lnsurc lor {orksi .onFnsarn,n. ,s po,idcd forbtScctiotrlT0ooirh.
<br />bt, cod.. tu th. lcrfonmncc oI lhc rort tor which lhc p.nnil n is$cd.
<br />-l
<br />harc rtu will minlain *nrker' ompcnsarn,n in\!r!ncc. ns rcqltcd b, sc.rbn r7o0 ol Dc bbor abdc. fd thc p.rfomtud of
<br />rhc work rbrwnichlhk ncmit is i$kd Mysorkcn conrp.nsalt)n io\rx'ft.adi.t md poli.y Nnh.r uc
<br />-l
<br />ccniiyrh.l nr lhcrcrlormonccollnc wort for shichlhn pcnnir is h\ucd,I shrll.or cnrfloyony,)cmn in.nynunncr
<br />w, el ro N+om $hid b rh. wrnk.n .smFnqrhn liw{ or Cnlitomm, nn,! a!rcc rhlr if I should h{com slhjar k, rhc
<br />srrkes' $nfcnsariotr pn,visi.* of Sc.r ion l?00 of rhc bl.r c{tlc. I sh.ll. lonhwith comtly wilh lhos prolnionr
<br />llARNlN(;: rzirui. ro s.urc workc,! conrDcn\aliotr .ovcasc is utrhwril. dd slrll \ubr.r M cnDlo)u ro ainrinal lcnalrics lnd
<br />.ivil fi..s up kr oft hundrcd rhoustrd dollire (SILD.UJ0)
<br />SNtion 1076.r$c Lrtsr C.dc. intcrci ond altomy s ies.
<br />in ldrlili0n n, rhc co( ol drtrr'gcs as nrovidcd fo! lhc
<br />IIECLAAA.IIO!
<br />I hcEb, affim !.dcr p.tulryorFrjury lhar I ffi liccDsd und& tmvisiotr ot Chaltcr 9 (onmicing sirh sdirn 700oJ ofDivision 3
<br />ol rhc Busirc$ .nd Pmfcsions Cndc- atn my licenr h in tull forc and caart
<br />-o-(e
<br />CANiIBI]SIONIEIUNAACEI.CI
<br />I hcEby nfllr und.r Fnrny oi pcrjury dll lhft is a conslru€lion lcndinB ogcrcy f.r rhc pcrlormnc. ol lhe work for *hich lhn Fmn is
<br />hsucd (Scc. 3017, Civ. C ).
<br />AXSLIqANL.PECI,ASAIION
<br />I hstt, !,im lndcr lcnllryorFrjuryonc or th. rolbwing dcclmrions:
<br />Dcmlirio. Pcrnih'Asl,csror Norifrarion Fcderal Rc8ularion\ (Tirlc 40. Pd6)
<br />-Rcquncd
<br />t.rrcr of NolifElhn
<br />I.cdifyrh.r rhc fL{cril lc3uhrions rc8ffdin8 rsh.nos rcnnul nrc nor spplicahlctu rhis l)n*.r
<br />l.cdiliih|l I h.!c rcid rhh otpl
<br />nrdinonccs s.d Sldc Lrss relarirBk,
<br />i\.oftd. I aem roconllywith.ll Cirylnd Counr,
<br />r.rr.rc.rdivcs olrhis ciryaM c.unryro cnrs rnon riF
<br />ntrlc rcnrio.cdfmpcnylor
<br />Appllonl or Ag.nl SIBmtuF ,",,, 9'9 -'d
<br />"",", f-4- '9
<br />tt
|