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ELECTHICAL-INSPECTOR RECORD
<br />OWNER BUIT,DER I}ELCARATION
<br />I hcrchy ntfirn' u.d$ Fnahy of pcrjury lh.l I .nr cxcnpl lmrr lhc Conlrrctor' Liccn* l-aw lbr rhc tol]osing rcasn (scc.7oll t
<br />Busincs and Prolcssion Codc) Any Cily or Counry ahth rcquires a rEmrir xr on{ru.r. 8ll.i iq) vc. dcmlhh nr rNn any
<br />{tu.r!.c, prjor ro nr i\ruaft.. dl$ rqrifts rhc appli.anr rd so.h Fnnir to filc , sig.cd $a'.m lh0l ft or shc k liccn{d pureanl
<br />lo rhc rovkions ofrtE Conrrchis Liencd Llu (Chr/cr 9. Commncitr-s wirh Scclioa 7(,00 of Division I olrrk Busin.ss and
<br />Pofe$ions Codc)o,rhlr lEo!sh. i\ crcnut ihcrcfiom and rhe hlst for rhc allcg.d .rcmprion. AnyviohlionolScclion?0:ll.5byun,
<br />applic,nr tb. a p.nnit subj{k rnc 0ppli.nnrlor.ivilp.mhyolnot.uellln6vchundrcddoll.s($5OO)
<br />-1.
<br />N osrcr of Ihc protErrr- or nly cmployas wirh uascs !s lhcir M,b .o'nr.isd i.n. sill d
<br />'rE "trk d llt ntrr@ n mr
<br />imcnk! or oucrcd li,r sk ( Se 70,1,i1. Bxsinc$ rnd Pr,rcsn,nr C.d. Thc Conr{rol s Liccnsc Lnw docs not rylly lo !n owtut of
<br />rhcrmEny who huilds or irpmrcs lhcror ond who des sch Mnt hinNclfor tcrrlfor rhrcush his or hd ownenployccs.
<br />Drovidcd rhar such iq)tuEftnts e fr, ir cftlct or ofiR{ for eh. lt tr)wc$.. rh. ttrildina or irv,roEE.r i\ sU knhin rc ,u
<br />ofsntLriJn. rh. Ownd Buillcr will hnrc rhc honl olpmving thd lEorshcdil mt hildorim0mw thc ImFny fir rhc putrt of
<br />t. N.wncroflhc lt{llldy. ancx.lusivcly.otrtacrnrg wilh li.cnscd.onrmrors ro cotr(ru.llhc pmrccr (Scc.704-{. Bu\irc\i
<br />nndEnri:shnCodclhcContBctoisLiccnscl,a*docsnolopt'lylo!nownc!orprondyshohrildsorimPtovcsrhcrcotr.
<br />rnd who .o.rhch for so.h pmj{rs *nh a A mcro(n [c.ns.d ruBurnr !, rhc Contrudols Liccn\c li*)
<br />I um.rcoti undc, Secrir
<br />lrlla6.I&:J;aufENsd.rll)N
<br />DIiCLABIII9N
<br />I h.rcby nffn undf F.dhy or Frjury otrc of lhc rallowrng dcchnr ions:
<br />I hnvc Jxl willtrrinrrinaCcdifi.ii.ofCr scir n) Sclf l'i\urc L, wdrkcya cotrrDcnsnliflr. r\ pr'vi,lcd lorbyS.dnnr 17(x)olrh.
<br />litxn G'dc.lor rhc F-rforron.c o{rh. {ork frwhirh rhe pcrn,ir n is\td
<br />I hrw,nd eill,n.inlai. workcrs .ompcnsaliotr insurncc. as rcqutcdbyScction3700oflhcLlborCdd..f rhcILYlnnMn col
<br />rhe work rar whi.h rhis pcmit is issucd My*ork.s .omNnsation insurancc qnicr lld policy numbcr ml
<br />c""r", 'Zuri ch Arqer; Lorn lt'rsvrun.e C-o.
<br />-tt'lcotlLlo9 r"pi,*,-JO-I l- ?etA
<br />-l
<br />ccnilyln inlhc lcrhrmNcol rhc *o n, whichlhi\ pcrmir is ismd,I \h,llnor cnrd.yany!.rsotr itr trny'nrnct
<br />e, ,rt,l*o r.uhFrr t, rh. $srkds snqrnsarion l,wsorcdirn r. and oBEc rhir ifl shnub nccom sul,jd b rh.
<br />*6rk.6 comp.isrrion povisn,N ofS..rion 37m dfrhc lrb.r Gltc.I shrll.li,nhqith comtly wilh rhos Imvnions
<br />WARNIN(; l.riluE n, {cur. qo,kcrs'..n,Fnsii,,,rugc i\ unhslll. rnd nrll {rhjc.r rtr cnll'loyrr n, dinimltrn.'lrics rtrJ
<br />.ivil lin.\ u0 k, onc htr rcd rh.uvad r1l .ofrrcnsrion. dua8cs .s p.o!id.d thr rbc
<br />Sccri{ :rl)76 ofihc ljtxtr G c.i' cr.{mddr
<br />-2o19
<br />Dru.lu -MJl
<br />I hcrcbr rlfirn undcr pcndlry of p.rjury rhrt I am li.ctrwl rn&i pmvkion olChtrcr 9lonrnrncina Nilh SNIion 7O0O) ofDivisi{, -l
<br />oi lhc Ausine$ und Profc$ions Cod.- ud nrrliccnrc h in tull f(tre od cfla.r 7'
<br />CIO AC.l' B t8+
<br />,,,,," $-tl'lirS
<br />kndc'\ Addrcs
<br />-
<br />l.rnil,vthdrh.,cdcrrlrrArhrtr)nsrclddir!r\h(no\rc nrrLrft or rtt!uhlc ro ihi\ nn,jccr
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unil
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />lVleter Release /t/Utt tXN-{
<br />Rough
<br />Ltru/rs 5^qs
<br />FINAL z[t4l,t /unlD
<br />Notes, Remarks, Etc
<br />I ccniti rhar I havcrc lhis0pplic.rion0nd{.rcthorth.0horcinrbrnDrionhc.rer lasrero.odplywirhallCny,ndcoutrry
<br />il:r::lk*ilriPJ-ruP-
<br />*'
<br />^ "'
<br />:," g':,; -"ffi "
<br />c.ni:* a"-",p;"',24u@. hAtO e.
<br />qANiIAUCUIINIEDIXG.AGENSX
<br />I hcrcby offtrmundcr lcnlltyofperjurylhot lhqc is a @nstoclion kndins as.ncy lor rhc rdrortunce orthc work fo! which rhis lcrmil k
<br />ssu.d (scc 1097. Civ C.).
<br />lxrdcr'. Nom
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<br />AT]UIANLI]ECI,ASAIION
<br />I hcrcby rflim undcr pcnalry orp.rjxry.ft orrh. follo*int deleariong:
<br />D€mhion Pcrmits'Astlslos NorifE(io. Fedcrll Rc8uhlions iTnt 40. Pd6l
<br />-Rcquircd
<br />Gttcr olNorifi carion
<br />Service Meter
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