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ELECTRICAL-INSPECTOR RECORD
<br />ID/SIG.COMMENTS OI\IIER AUII,DER DELC]ARATION
<br />I hcrchy afiliin uM$ pctrdlty of pcrjury lhar I ofl crcmpt fiom rhc Conlncro6 Liccn* tas for rhc rolLwinB rc.$n (s..7011 5
<br />AusiDcss md Profcsion Codc)r Any Cily or Counry shich rcqutcs u pcrmn kJ .on{tu.r. ahr. imEovc. dcnrni\t ,tr rcFn rnJ -
<br />srrucrurc. priorro irs tsuancc- ol\o rcqlir.s rhcappltad nn uch Frdir !. nl.rsiStrcd slllcmir rharhcor shc n lic.nscd r!^uanrrL
<br />ro rhc,K,viib.s oflh. Conlrncror's Liccnscd tiR (Ch!pt.r 9, ConrnrE-'ing wirh Sc.ii 70(xr of Division I ol rhc Eusincs.nd
<br />Pmlcsbns Codc) or lhal hcor shc hcicmpr Ocrcfromandrlrc hlsn li[ihc rllcg.d crcnqrnin Anyviol0lionolSccrionT0.)l5l,yuny
<br />nprlics r o pcrnrir sul,jc.h rtu {tlic.n o,.ivilFn,lry.rnornb(th,niivchu.d,.rldolla,s(S5(x))
<br />l. as owtur ot rh. Pl,Fnr. oi ny .mFlrtc.s eirh sngcs n\ thct a,k sm|rnsdio., tr ill do rh. wk and thc {mrm i\ n
<br />inlcftlcd or olbrcn lor sh (SN ?01.1. Busincs and Prolbsrhns Codc: 1 hc C.nrs.kt s Lkctr* tr'w dcs tro' .r'tly h an owmt of
<br />rhepol]cn, wlar huild\ or infmvcs rh.mn. d wh. dfts skh wo* h inNcll or hcr*lf o. rhmu8h hh or hcr own .fltloyccs.
<br />ndvid.d Ihsi ru.h i tmwmnB m nor imcndld n otrcred lft\{lc.ll hosr\u, fic h{ikling or iryrmEmnl issUwirhinorc }tr
<br />or on\.hlt n. llE Owmr Buiilcr will h.vc lhc burdcn oI pmvins lhd h. or ric d'd nor huiid or itr rotr rhe InJFiy ror lhc purlrNc ol
<br />-1.$oNnc.olrhcflopeny.!rexclu\ivclyconrracri',ssirhli.cn{dcoitr.rr^b.o
<br />srucrrhc lr)jccllse.' 7lH.l, Bu,i"r$
<br />md Pn)fssi'nCodc ThcCoita.ror'sLi.cnscLnwdocstrorattlyrr)rtr.uncroln(,|rnlshobuilds.rnnfturcsrhcrcon.
<br />rD{l $lo onrrrr\ for such projccr\ wnh a Contlcron \) licctrsd nunM t, rh. C.fir.rtr's Lr.cn* trw).
<br />-l
<br />amcicmtru.lcr sccrnnr-. a. & PC. forrhh rcrsotr
<br />lYOBtrll&rl:lJI.lfl,N$rIIIoND[!L .8Alr0!
<br />Ihrvcandwillfr.n ain wortcrs co$tctrsaliotr irNuramc. as rcquircd hySc.ln,n lTmof rhc tjb.rCodc. for rhcrclio.mrnccol
<br />thc sork lor which iht pcrmil is isnd. My wortcrs conrrns.l ion insurarce caricr ard plicy nun$rr tr :
<br />vaPl-16
<br />rf
<br />CONEIAIIIIJNIENDI!{iACENCI
<br />I hcBhy lmrn undcr Fn,hy or p.rjury rha' rhrc ( a .onstodb. Lnding i8lmy for thc p€'ihrnrmc of rir *o* for whhh rhn ,trnil ic
<br />ksuedlScc. 3097,Civ. C.)
<br />APPIICANLDECI.ABA.II!]N
<br />I tf,nby (trran undcr Dcn.h y of Dcriury onc ofrhc lolk,*inp dNlarurions:
<br />D.Nnirion Pcrmir$Asb.slos Norific0lion Ftdcrol Rqllllions (Tnt 4), l'an6)
<br />-Rcquncd
<br />tf,llcr oi N.rifi calion
<br />I ccnilyrharrhcfcdcrrlftgulrrions rcld'lirg rnrnosrcnhvdrrc mr imlarbL u rhis nroF(
<br />I c.rliliihnr I h.!c rcndlhn trlpliolionmd llcrl{rlhcrtlvcnrlormarior iscotrccr I rarrhco DlywirhnllCiryrndCoutrl,
<br />odituftcs Md strrc tjws rll(ir8 robuildir8 rucrtnr. and hcrchyuuhtriic'.pr.snrdnrs.f rhisCiryandCornryrocnts upotrlhc
<br />rh^c 'ctrri,rrtl t'.t)r'rJ ,,tr '\
<br />.\pplionl o.A[$lSi!nHltrrc
<br />Irrnrilre Mnr. (Drinl):
<br />x ,,,"44fe
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Lighl Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilinqs (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rough)
<br />Ivleter Release
<br />Rough
<br />Service lvleter I
<br />FINAL Qlnnlttt't onr^,,;7-e)
<br />Notes Remarks
<br />APPROVALS DATE
<br />Translormers
<br />Etc.
<br />I hcrcby rfirn undcr rc.alry ol p.rjury or ot rh. tdllo{iis dccl@rioni
<br />-l
<br />havc adl * ill tuinr,in a Ccdifrdl. .l C()n*.1 to sclr l nstrr. ror worlcn comrnsl ion- !s lovidcd &tr by Sccr ion l Tm af $c
<br />lihor Codc. for th. pcrfomme ofrh. sort for whth rhc pcmn ir irsucd
<br />I ccniry rhat nr rhc p&ronMmc ol thc qort aor which lhis F.rn is nsud- I sh3ll nor .nrloy any l.rstr in 0try
<br />'natrne!s slo bcom subiccr to thc wortcr' coryrlslrion la*solcalifomi.. and,st. rhar irI slsuld hc.om s'hrEt l. rlE
<br />workeN conq,.nsorion nmlirions nlS..ri.n ll?fi) ot rhc lihor Codc.l \hll. fodhwirh omply wirh tho{ pnvnior\
<br />WARNINC: F,ilur. ro s.urc $ork 6'comlcnsariotr.overaEc r\ unlr$lirl. \h3ll \uhFr rn onrlorcr h nimin.l pcnlllics otrd
<br />.iril fincs up lo om hundEd lhousand dollus ($loo.fixr). .aar6tr o rrrc c""r ,,t .omrrydiL'jlr dmrAc! oi Drcvidcd for lhc
<br />s(r,on ru,6or rhc tjts, codc. mrcrcj lnd 'unrm) stu.. Zl4--------- t [ ),"*fuIY n*u-"*, t/*L/<rP{
<br />r ('4rFi)( oNTR croR
<br />DEII.ASAIIAN
<br />I hcrhy arfi,m undcr pcnxlty oi p.rjury rhd I dm tuinyn xndlr pmvkio. orChipls 9(commncin3 wilh Sccrion 7(XD) orDirision l
<br />ol rhc Dusircssand PreicsionsCodc. md hrlicensc is in lulln,rccaidcffc.r.
<br />^&f tql
<br />t ndcir Addr.N-
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