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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUTLDER DI]T-CARATIoN
<br />I hcrchy aflird onddr Nnixy or Frju,y rhrr I!'nercmrr i-.ir," c."r*a*' UccN Ii$ fttrrh. rollowii '.!-n (s:.70rr 5
<br />Bu\ine* aid Pi,,fc\\idr Cq,cl Any Ciry or Cot y whi.h r.qutrcs r IE mir i{) .onqfl.r. tlrcr. io!'mve- dc rlkh or EIan iny
<br />dru.rurc.Innh ik i\sudncc. lls rcqun$lhc applicatrr lbr $,ch rflnir !i filc ! \i3ncd \rsrcnEnr rharhor shc ir liccn\.d PuntMr
<br />ro lh. Fovi\ions of rh. Conr0.rors Liccnscd Llw (Chlnrcr 9. Co'ntrrRin8 *irh Scdion 7lx)O of Divnion :l of lhc Bu\inc$ and
<br />Pn,f.sn,n\ (_,)d.rorthd lrorshc h excmnr rhqcriu rtr,l rhc basis lbr lhc lllcEsl tr.nflion AtrylnnarionolScrhnT0:ll Shyany
<br />aptlicmr lornllcnnit cDhJLrls rhe rptli.rmba.ivilp.nrlryofnolnv{crh$livrhundtddollan(1500)
<br />l. a\ uwrrr of r hc FmtEnt. or my empk,Ft\ sirh wiSci r\ rhcn $1.onlF.nsdi,'n. *illdo rh. wo* oM ltr (rrm'i\ nor
<br />ir dkkd or olt.r.d for elc ( S( 704,1. Bu\ii.s ,nd Pn,f.\li.ns Codc l'hc Conrmcror'i Li..nsc Irf, dtrs m,l q,Ply ro m osrcr of
<br />rh. Dmpcny $ho t{ilds or imro!6 rhcmn. .nd wh. dds skh s. himscllorhc^clforIhhuShhhorhciornrmplorc.\.
<br />pn,vidrd rhrrsu.h i'nDn'rcmnridc nor inrcn&rt or oficrcd t{n srk llh *tvs. rhc hoildin! or i'np(^otunr c $kl wirhinonc tlu
<br />ol'.otrDlerion. rhc O*n$ BriHcr willhaR lh. ttrdcn oI F)vin8 lhd h. or +. did mr hoill or illlB'rc lhc PRrIdt aor ilE PUrF)sot
<br />L rsostr.rofrhc fmpcdr..nrc\clurivcllconrrcring trirh li.ci{d.onlru.lo^t,.on{ crrtFPmi{t(SN 7OlJ.B.inFL
<br />ud thri\sim c(nlc: Thc Co fta.ror s Li.ctr\c Lrw docs nol apply h n osncr .l lron n y *ho hulld\ or inrpkrv$ rhcrcon.
<br />rnd who.uDtra.Flrrsu.hFoJccrsnirhaG)ntrckdnlictr*dtNNrrrrr{'rhcConracrtr\Li.cn\cLsw)
<br />IrcB&;BT]1;OAIIEASA.IION
<br />UECLABAITAJ
<br />I h.r.hy rllirni oidrr p.n.lry oft^-rjury.rc.lrhc tulk,sing drclrRri{rF
<br />-l
<br />rrvcoxlwill roinrrinaCcnific{t.olConsenrro Sclf lnsure for workdC omPcnsrtion. as F,vided fo. byS(lion:l7lx) ofrhe
<br />L,hor Codc. lor rhf Frfomn.. orrhc qort for shich rhc permil is ksxcd.
<br />I havc rnd will trrinhin worlcra comncnrdr id ihrurrn.c. rs .cquircd hy SNr bn ]7m .l rh. IjtDr CoG. lor rhc p. orruncc ol
<br />)!,-P hrhis pcflnir i\ isu(l M!{orkcr!.o rfci*l( ]trY .rrirr ,xl r1)lry nunrtf,r rc:
<br />vzrzSr )ona
<br />/ ,,*.2 )
<br />lccnily lhar in rhe F fo'nukc ofrh. work lor shth thn rcrmil i\ i\\!dd. I thrll nor cmploy Dny pcr$n in iny rnlnncr
<br />vr s h h.mtu \ubj.rr rorh. workc^' conEns0r ion l!{sofCrlilornir, rtrd.8e rharif I sh,rld h..om suhicct io 'lt{orkeF cory.nrnri,,n Frvhiofls olSccrion:17(xJofrh.lihr Cod.. r rhdll. fodhuirh q'npl, (i'h rhos Provision\t
<br />WARNINCT Prihtrc ro surc sorkc^'conr.rsrrio. ovcmSc is unhwful. ntul sh,ll \uhid an cmployer ro di nnll FMlri.s ond
<br />c,ril tlncs up ro orc hundred rhouqnd dollr^ (SIO0.filO). in oddnn'n h rhc c.n ol .onEnqlion. dinhg.r $ prorid.d for thc
<br />S(f'n :1076.lrhc lnhtr Codc. i' crc{ rnd du
<br />h, 'i
<br />I hcrcby altirn undcr FnalryofDcrjury rhar t !m licenrd rn&r pn,vhh oIChorrcr 9 (conmminS sirh Stclhn 7(](r)).rnivnnn l
<br />of lhc llusines Dn.l Pn,fcsrions Codc, ad nry licen€ is intulllor.Tn lcfld.
<br />L'rS s05
<br />72p7rutazg
<br />CONS'I'RI]CTI(tN I ENDIN(: AGTNCY
<br />I hcrchy alrirmuMcr pcnalry oi ncrjury rhi rhcre i\ r.nn{ru.ri([ ktrdirE t8cmt f{n rhc p.rfomlnrcc oI rhc tr.rk lor ahi(h rhis lcrmii is
<br />nsrcd lscc.1097. Civ C )
<br />AIILICANLDESJAAIIQN
<br />I h.nSy ofiinn undcr lenahy otr.rjury oft olrhc rbllo{i.e daharions
<br />Dcmolirion Pcuils-AstEno! Norifi.dion F.d.r0l Rc8uklions (Tillc.l0- Pd6,
<br />-Rcquircd
<br />Lcller of fi.Jrifi carbn
<br />I clniryrhd I htr{rc:(lrhis appltrrn and {rrcrhd rhc!b!c inlhn.rion i\r.m.r I erccroconrplrairhrllCiryrndCouniv
<br />ordiMi.rs nDdSrat. tiwsE!(in8 r. btilding c..dtucrn !, n h.rciyourh.nrcrrfr.\cNalivcsoflhi\CiryJndC.unrvrocnlcruF,nrhc
<br />t
<br />g s'a,'
<br />6/</b
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER ?/zc[tt ,(.ltl4'n.,
<br />Translormers ll
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Sollit Rouoh
<br />Ceilinos (T-Bar Rouoh)
<br />Meter Release 8/"-alrq,4/1/41 )
<br />. _!,
<br />Rouoh vl>vt/1 _.{,,atso,
<br />Service lt/eter r /
<br />FINAL /L/?b/if fLr/L /u1/
<br />Notes, Remarks, Etc.
<br />B & FL r.rrlrr rcrsctr
<br />Dlre o*nrr
<br />e4{
<br />Irnd.rs Addrc$
<br />-
<br />I ccniryrh,r rhcrcd(rlrcEuhrion\ rclrdingr\btd.s'c Irili,. tror Jplli.rhlt t)rlri\ pmi.cr.
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