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ELECTRIGAL-INSPECTOR RECORD <br />APPROVALS ID/SIG.COMMENTS <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Si ns (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Transformers <br />Torquing <br />Sub-Panels <br />Alr Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilin s (Hard & Soffit Rough <br />Ceilings (T-Bar Rough) <br />Meter Release <br />Rough <br />Service Meter <br />FINAL <br />Notes, Remarks, Etc. <br />OMcrBuildcr Dccld.rioh <br />I h.Eb, aflim undo Fn.lty ofpajury (hal l o cxdpl fom lhc ContBctofi Li..n!. Ll* for tn. followinS r.aon {scc ?OI 5 Bsinqt <br />aid Prcf.$ioi Codr): Any Ciiy or Counry which rcquir* a pcmir lo consrruct, alr.r, improvc. d.holish or !.p.n My rructurr. Fior ro ils <br />iss@cc, ako rcqutG rh. arplicaDt ttr such Fmn to fiI. a si8n.d starm.nl rhat h. or 5h. h licascd puBuar lod. prcvisio3 of thc <br />Cot arci! Liccied L.w (Chart , e, Comm.ncins wirh s.ction 7000 oa Divirio 3 of $. Buins Md PofeioN Cod.) or $ hco <br />lhc is.xcmpt thcrcftm &d fi. bsis f6lhc rll c8.d .x<mpr ion Any violirion ofScclion 70ll 5 by dy appticdr ftra pcmi subjdt fic <br />applicel ro a civilpd.lty ofrcI morc thd fivc lundr.d doll& (t500). <br />_1, 6 ownd of th. FDp.rty, or my mployc *nh *ag6 6lhcirsolc @mp.ns.rion, willdo $. work ad thc rrtucr(c is rot incnd.d <br />or ofl@d for salc ( Scc 7044, Buin6 dd ProfBsions Cod.: Th. Contr.crort Licd!. kq do6 not apply to u own.r of rhc pr@.ny <br />who buil& or improvB ih6@n, ad who dG slch work himcll or h6dt or throuSh his d h9 @n .mptoy.6, Fovidcd thar slch <br />improvm.nE u. not inlddcd or offa.d fq r.l. Il hNcv.r, rh. buildin8or improvmor is sold *irhin on.ydof compt.l,oD, th. <br />OwncFBuildd will hav. thc burdcn olproving lhar h. oi sh. nol build o! imprcv. for th. purp6. ofs.lc). <br />_1, a own(oftc prop.ny, d cxclusivcly conrEring wnh li..ns.d @.Eacro.! ro connru.l $. p'ojal ( S.c ?044, BBin6s sd <br />Prof6sion Code Thc Confactor's Lic.tuc Law dGs nol apply lo e oMa of prop69 who builds tr improva rhdcd , dd *ho <br />.ont.cB for !u.h proj.cE with a Coir&b(, li@nsd pusu r ro rh. Conrador's Liccns. Law ) <br />_l d adpt un.Li scclion _,B &PC fdfiisr.Mn <br />WORJ(ERS COMPENSATION DECLARATION <br />I h.r.by affim und.r p..alty of p.rl!ry on. of rhc follovi.s d.cledio.t <br />_l havc Mdqill maintrin i C.ni6cak ol Co.scnt b S.lfinsur. for wolk.E conpnssrion,6 providcd tor by S.c on l?OOofrh. <br />Labor Codc, fo, thc pcrfmdcc of th. work for *hi.h rhc p.mn is i$u.d <br />_l havc ad pill mrinrain wtrt.R compas ioninsurecc,s r.quir.d by Sccrion l?00 ofrh. LaborCodc. for rha p.rfomuc. ofrh. <br />work for shich lnis pmit is isru.d My eo*d'cohFnsltio insur c. csid ud policy numbcr arc <br />(ThG s.ction D..d nor b..ompl.t.d ifrhc pcmn is lor On. h <br />-ft^,*,6-..*. *6r <br />rhd in rhe plrfom cc of rhc work fm which <br />EI toth. work.B comp.nsation la*s olcal <br />conp.nsarion prorhioB of Sccrid l?00of th. L,borCod., I shall, fonh*nh <br />o^"l-2 44-o L <br />WARNING FailuEio seuE worL6 @mp.nsdion covcra8. t <br />fin.s up ro on. hundr.d rhousDd dollst (1100,000).rn rd.ltrron ro <br />rhc bbor Codc, intcr6! od doh.yk i.6. <br />I hcrcby aftlm undd p.nalry of prjury rhal I o lic.rs.d undr provisioi of Chaptd 9 ( <br />thc Busin6s &d Prof6i6! Codc. ed mt licnsc t in full forc..nd.ft@t <br />Licctrs. Cl6s _ Lic.nsc NLmbcr <br />"^,,p1 )--2.tt - ol\ <br />I hr.by afiim u.d6 p.ialt, ofFrlury rhat thq. ir s @ottnctio, <br />ilsu.d (S.c r09?, Civ C.). <br />APPLICANT'S DECLARATION <br />D.mohio. Pmit-Asb*ro6 Nolificalior F.d.rcl R.gul.rions (TnI.40, Pdr 6) <br />_ R.qon.d Lct rofNoti6dion <br />ro comply wnt aU City ud County <br />abo!. m.ntion.d propcny ior inspc.tion purros6. <br />ofthirCiry dd Counry ro c.rs upoi rh. <br />1/,/, <br />)-->//-4 <br />DATE <br />t,{ffiAED <br />I \M0 0"49,2o6 ..- -