|
ELECTRICAL-INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER BTIILDIiR DEI,CARAT!oN
<br />I hcrcl,y afliir. under ncnalry or n rjury rhal I m cxcmDt lmm lhc ConlrdoF Liccns Law fo! rhc LU.winB rclsn ( Scc 7031 5
<br />Businc$ and PofE*iod Codc): Any Cily or Couniy wfiich rcqotui I lEnnii lo mn{ruc|. slrcr' nupmvc. &mlish or elxir a.v
<br />sru.rurc, prior ro ils ksurnce. rho rcqui$ rh. apllkanr f.r sxch |]cnnit lo filcasisn.d s cmnt lhalhcor shc i{ lic.n\.d lnrsml
<br />ro rte nmrisio.r oa rhe C.nractols Li.cnrcd t w (Chapler 9. Conm.midS wnn Sccrn,n rfl)o orDivirion -1oflhc B!\ioc*,nd
<br />Ptufc\\tunsCodc)orrhat h.orshc iscrcmpr rltclrcn rn{ rhc bnrtu ror dr rllescd erchPrion AnyliolariotrolscdknT0-rl5 hy t
<br />ippliconl l'or 0pcrmir suhjcchrho dttlicant ro acivillrnllryolnot nBrcrhan fiv. hundr cd dollas (S5m)
<br />-1.
<br />,s ouno or rhc trclEny. or m, cmrl.yes wnh w.8cs !s rh.ir blc comPcnsd ii,i. aill do rh. *ork 0d ltE {nrlur i( n.r
<br />inr.nd.d or oficEd for slc (SN 7(!,+. Blsinc{s ,nd Proltsio.s Codc 'l'lc Conrracrof ! Li.cns. hw does nor aPplt lo nn oRmr oI
<br />dc pmlmy who builds or improhr thffin. lnd who &s sth w* himsclfo! hdr\.lr.r lhroush hn or hcr osn cnDIoyes.
<br />prcvidcd rhai och i.l,oEmnrs.e rnr inrcnd.t oroifc..t lor$k lt h)ac$. rh. tDiklirg ot inDm\tmd i\ $ld withinnnc )cr
<br />o,conrrkri,n. rhcO*ncr Suiud sill hrvc lhc horden of[.ving rhd lk or xjdid mr ttrildor iqrow 6c pn{tnv for lh. puqns of
<br />I. ss osn.r or rh. tmicty. anrcxch\nclyco n rio! si(h lic.nscd conrmclors ki 6idtu rrrf,ltuar(Scc 7o'r'r. Bu(itr(
<br />rld ftofc$6n Codc Thc Conrd.r.f s Liccnsc Law docs nor onnly ro !n o*n& or Dmp. y qho hu ilds or impror$ lhcrcon.
<br />and oho c.nrd.Bfor suchnmrcIs*irh a co nrrucknl r ) I ic.n\cd ru*uotrlto lhc G,nirrcktr r t-ionsc tjw)
<br />I !ncr.ml trndcr scclio
<br />Dale Own.r:
<br />w(!nKF[s a:attrrP[|\SATI()N
<br />DECLABA.IIIJ!
<br />I hcr.l,y,ffiim ututcr prtriltyorFrjuryoE ot rhc rollowin8 d*lardions
<br />-l
<br />hs!. ,nd will mn din 0 Ccrlilicarc of G,nrnr b SclHnrur fd tork.6 .ooDensar i.n. rs pmvidcd ior h, SEr i(,n :r70O of rhc
<br />L{h, Codc. (tr rhc p.rrormncc ol rhc Po,k for which lhc Pcrmir i\ i$ucd
<br />I [iE rnd willnuinkio wo*.rf.ontEtr\rrn,r inrurrn.c. a\ rcquncd h, sc.rion:17([oflhc Latxncod.. forrhc lcr,hrnBrc or
<br />rhe work l'or whi.h rht pernir is hsu.d MyNorkcn Nml'cnsdio! iisoran.. .afticr rnd Policynumbcr ml
<br />l.cnilyrlrr in rhc pcrlorrotc of rhc $or* for shi.h rih Nnnir is i\{r.d.l nDllnor cnulnyanyl)cr$n inrnynunmr
<br />so sh hcunm subjcd ro rh. nrtc( comlttrstn,n liss orcrlir(n id. md tArc hd ifl should hconf, subicl b rh.
<br />+,orkcr'conrFn\arnrn,n,visionsotScclio:U00oIrh.latrC,.,Isllr]1.lonh*irhco'nPlyairhrlD$ln)visions
<br />$ARNIN(i: Fnilurc lo scurc workc^' comPrn$ln,n .o\sr8c is unluNful, and shdl subicr 0n cmlloFr b rnninrl ncntrlrts and
<br />to onc huftd..d rhou$nd douds {$loo.0oo). in uddnion k, rhc cosl olconlEnsalion da@8cs !s lrolidcd rbr lhc
<br />Sccrion :1076 ol rhc lihor Cnlc. inrcrcn md . onEy\ Icc\q/^1/'c/ (2
<br />^wti.nnt
<br />DESJAAU!]N
<br />I hcEhyamrmundcr l).noll, ol periury rh(l I rm li.cnscd undcr Eovhion ofChaprer 9 (.onrtrftin8 wilh S(rion 7qJ0) nlDivtion:1
<br />of rhc Blrinc* and P&fcsio.s Codc. and mylicen* h in lull tDrc. and cftacl
<br />",,",1/4y'->" tL .
<br />SONEItrIJSUANI.INI'IN1;IIiINII
<br />I h.rhy rfltm und$ ncmlly ol pcrjury r h r rhcrc h a.oh{fl.rkn lcndin8 tr3cncy ttr rhc Frfontuncc ofllrc *or[ lar *hich lhir Fnnil k
<br />i$ucd (Scc 3097.Civ. C )
<br />AfIUSANLDECLABTIION
<br />I ,rnhyrfiinn!ndcr pcnrhy of pcrjur! onc oirhc lollowins dcclarDrn,ns:
<br />L)cmlnion Pcrmir! Asrrsos Nolific.tion ftdcral RCEUl ion\ (l'irlc40. PMO
<br />-Rcqutun
<br />kllc!.t N6ril^ldion
<br />-l
<br />c€difr rhd tlr f.'i.ral rcnrlntions Bgudinr ashc{ \rc nr nl arc mr .Pnli.lbh h rhk pn,l..r
<br />l.c'rili rhrl I h.\c rn(l rh \ rnl)licrri()n rtr(t jal. Ihrr I
<br />ordi'itrr.\ rful Srnr. Lr\\
<br />rtn\r nf,trri(ntd |x,lcny
<br />ApDliLrnl or Aa€nt Sign{
<br />r comrly warh rll cityand Coutrly
<br />rhh Cirylnd Con y ro cnls upotr rhe
<br />,,," ? /t,t/tltg
<br />Site-Work
<br />Underoround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Bouqh)
<br />Ceilinos (Hard & Soflit Rouqh
<br />Ceilings (T-Bar Rough)
<br />lvleter Release
<br />Rouqh
<br />Service ltrleler I
<br />FINAL til 3+/tO -T{7,tMp?d
<br />Notes, Remarks, Etc.
<br />APPROVALS
<br />trMcr.\ Addrc$:
<br />-
<br />I
<br />I
|