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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATI('N
<br />I hcEby lrrm u ler pcnalry i'f Frinry lhal I onr cxcmpr fon rhe Conlruclos Liccns bw aor rhe f.llowin8 rcas'n (scc 701 1 5
<br />Busioe* .d Profcsskrn Cinc): Any Cily or Counr, shth Equtcs a Pcnnir h construcl- !hc! inptovc. dcmolhh or nplr onv
<br />rudurc. prior ro ils iisu"kc, tl$ rcquncs rh. q,plkMr lor su€h IE..ri ro filc tr siSmd narcm th0t hc ot shc is liccn*d pu^uur
<br />ro rhc pnrvkions oflhc Conk,ctols Liccnrcd tiw (Ch{rcr 9. Co'nnrcncine with Scclion ?00) or Divhion I orrhr Bulnrss and
<br />Pnfc$in\ Codcr or rh0l heorshc ncxcnu rhcrcirom md rhcbasis f.r thc alk!.d .x.mption. Anv vidurionofScclinn?Oll5 bv otrv
<br />rppli.anl lor r pcn.ir \nhjet lhc opplicanr lo acilitten.hyolnol nmdrhannvc hurd,ed doll$ (J500r
<br />-1.
<br />as own( of rhc ,oIcny. or d, orplotccs wid waecs rs lhcir slc omrcnsalion. sill do lhc wort und tlE slru:lurc i\ nor
<br />inrndcd orcr.d lu st rad 7044. Businc$ and Polc*i.ns Codr: fic Conrr ols Liccn* Ln{ d€s nol oldv ro nn .wnd ol
<br />rh. tmlEny who builds or LiPmEr lh.@n. aid qh. &!s sEh Mrt him\.lror h.rsllot rhduBh his or h.r own'6plovccs'
<br />provllcd rhar su.h in!$rcr \ m mt intnded orolic.ti for eL lt nows rhc ttrildin8 or iq,m€ftm is sld virhin onc ,u
<br />;fco,npLlion. !& O*n.r Buil&r vill hare lhc l dc. oftrovins rhal hc or sh. di] mt hild or inqmv€ th€ poFrl, ror lhc lrrPe or
<br />-1.
<br />osowNrorrhc tmp.ny. nmgclusiv.ly.onk&rins wnh li.cn*d .o.ttodos loq,n{ .tlhcPrcj.rr(S.. ?()44. Busim$
<br />lnd hntdsk n codc: Thc Conrr!.rors Liccnsc Luw doci n.r,lplylo ao o*n.. orlloFnv *h{) buirds o. inlFovcs rhcr'on.
<br />.nd sho conrrrh Id such lroids sirh a Co ncto(s)licc.scd tusuant to lhc c(,nkactl r Lians tis).
<br />I rn crcnpl undc. Se
<br />WORI(TRS' (:OMPFITSATION
<br />DECIASAIXIN
<br />I hcrsby amrm und.r lcmlty oa pcdury om of lhc follo*ins d(lnririons:
<br />-l
<br />hrv. dldwill minloin aCeninc0leolConscnrlosclr lnsurc fot wolkes LtmPcnstion. us l"ovidcd lor br Sdcrion lTi otrhc
<br />Labor Co<lc, 16. rh. p.rformt€ 6rrh. mrt fot which lhe petnir is hsucd.
<br />I h.vc ond qill muinrtin workcrt conllrcnsll ion inrumNc. 0s rcquird by Sal ion :1700 oa rh. bbor Cod. for ihc FrrornrMc or
<br />rlt w.rk li,. whi.h rhn lcnnit F tr\uci MJ $nrlq!'.umrctrsorr.r in.u'rn.'c (0nicr ud l'.h y numher ec
<br />fi-^rd.ak!k-K I (q
<br />l.cnilyrhar inrhc P.rfoinwrc (,I rh. w.rk ld shich rhis Ptrmir i\ isrucd.l \hrlltr i. ill('vaoy Pcr'n in'rvalnkr
<br />s tr\ ro bc.o r subj..r lo lhc (orkch coDlncnslri{nr lr*\ ofCrlifonrir. rnd rPftc thd ii I should ttco.t suh]lrr b rh(
<br />workcs conDcns rnr pmvisnrn\ ulSccriu lTlrorrhc tjh, Cr)dc.lnmll tunhwirh conrllv wirh rh.s fnrvhir)n\
<br />WARNINC Failu,c rn *.xr. workcn confcnsdnn ovcmsc n unhslnl. ud shrll \trhj.cr n. cmploltr k' nimin Fidhti 'nd.iril fi cs !p ro onc hLndrcd rl$qslnd dolldh ($1ff).0(x
<br />sdioo 10?6 ol lhc t-alrr c-o{.. ilrtc.cn and stofty's ies
<br />o"n' J72.2\4 upri*r,
<br />)r in rd,liri,nr t, rhc .o( .f c(drn grs r\ fr.\i(l.d ktr rh.
<br />DECI,ASAIP!
<br />I h.dby rmrm undcr Pcn,lly or tcrjury lh,l I un lic.nrn under Pmlirion or ChlPIcr I (.o'nmn in8 with S(rk'n 7u)0l or oilki'n l
<br />ol rh. BusineN .nd Prcfe$iotr\ Codc. s,t lny ticcn{ G in luu loNc sd clccr'
<br />t5 L o
<br />l-(cnsc Ntrnfi( L I .L
<br />.-,.,.,'.-) o\q \ tf\rr 5\q9rc61 -t'1 A
<br />C(TNSTRTICTION LENI)INC ACENCA
<br />I hcrby lffirm undcr F@xy of Pcriury rhal lhoc bt mnslruclion lcndane agcNv for rh. pdrotmNc otlhc work ior qhich rhis F nil is
<br />issue<t (s*. l09r. Ci!. C ).
<br />txndca'N,nr
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<br />AIELICANLDECIABAIION
<br />Ihdiby,lkmundcr0en ryorr.rjuryotrcoirhcf.UDwinSdccl{arions:
<br />ft nElirioi P.rmir$Arbesros Norifi..rion F{dcral RcEUlniionr lTirlc 40 Pan6)
<br />Rcqtr rcd t-cru,'l Norilicrrnr
<br />Icc'ilyrhrtuli,tcrrlrcgulrri,,Fr.giRl'ngrdt!f\rcouxlxrcnorntllici.r)rlr^ln)lc.r
<br />l.crlilyihrrlhrvcnrdlhlsnmi.xln)ixidnnrclh{rrhuilx,v.i'rl'rriliotri\coirtrrlngner!co Dldt wirh rllCiryrnd Couniy
<br />odimnccs Md Srarc lrws rcl,lins l{, l,uildii8 .otrNflr.tio!, md hcrebyaur CIy,nd Counry rJ cnrtr uI,. lhc
<br />x,v. mtrriorcd prcrcny td insn.rioo
<br />Appliu orAaenlstnnture ?'tz'({
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bondino / Groundinq / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Sollit Rouqh
<br />Ceilinqs (T-Bar Rouqh)
<br />Rouqh 1 tllt,d4r@ fri,^*. *,r
<br />Service Meter
<br />FINAL Alit/K,
<br />Notes, Remarks, Etc.
<br />1 \\g //1t t
<br />It/eler Release
<br />,1 A\g
<br />t ndfl\ Addr!\
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