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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.
<br />Sile-Work
<br />Underground
<br />coM:'-"-- \
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Founlains
<br />Signs (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondinq / Groundino / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Solfit Rouoh
<br />Ceilings (T-Bar Rough)
<br />[/eter Release
<br />Rough
<br />Service Meter
<br />FINAL z-1/ - t7 Zc z,
<br />Notes, Remarks, Etc.
<br />OWNEII BUILDER DELCARATION
<br />I hcrchy utfim undc! F.dlry of pcrjury lh.l I am cxcmll frorn rh. Conhcknl Licensc L€* aor rhc ti'llo*in8 rc,$n (SN ?0ll 5
<br />Bu\incs and Protc*ioi Cod.): Any Cny or Counry *hich r.quirs r Frmit lo con(ruct. !llm. imfrovc. dc'tuni\h or rc!,n ,try
<br />sid.rurc, r{r b irl issu.h_.. trl$ rcauircs thc epli.unr fttr su.h Fi,nir to 6h ! si8ncd (aremnr lhal L or shc Ls liln{J nuru
<br />ro th. Fmvhrns or rhc Contracror's Liccnscd tr* (Ch0fln 9. clm'*minB wnh Se.lio. TuxJ of l)ilision 3 ol lhc B!\inc$,n'd
<br />Dorcslions Codc) or lhar lEorshe h cicmfl Ihcrcfirmatrd lhchsis lor ttu allcEcd qcdpl ion. Any !n,hi('nolsc.rion 701l.5 by any
<br />applicn.l lir rtermil suhjalsrhc applicul ro acivilpcnrhyolrcl nmrclhln fiec hud,ed doller ($5(x))
<br />l. rs owfti olrhc ptuFny. ff hy.npk,F.r wirh wr8cs ar rhct yrc.omp.nsrrion. willdo rl[ work ard rhc srtrNN k mt
<br />i'lcnJcd or o,rcrcd fir $lc (Sm 7!?. Busims and Eolt$t,N Cqlc 1 hc O,nhctr\ I-i.c s. tnw Jd.s nor nmly ro nn o*mr of
<br />rhc nDlrny who huildr or inrlmvs rllmn. ad wh. dc srh wd hnns.lfor ncr{llorrlmugh hi or hcr o*n.hrl.ycc\.
<br />providcd rhdr su.h inpfl,vcmns rc nor i, cnd.t orofi.tuIfdr ek ll tnsc\c( rlE huildirB or inDmvcr*nr is $ld wirhin "rc,srolroil0brion. rhc Ownq Blil&r willhur rhc hldcn olpmins IMr hc or rhc did nor hxild or i'npmh th. pmpdly fo. rhc purlp$of
<br />l. rsowncr.frhc fl.Fyly. m.xclusivclycotua.ring *ilh li..n*d.onracb^ro con{nrct rtr rmrd (Scc. ?(!4. BusEss
<br />Md Pro{ssion Codc: Thc Conrrrclor's l-iccnsc Lop doc\ nor otply h !n owncr olproperry who hrildr or idDrot$ rhcron,
<br />Itrd whu.onrEcreldsxch!$jeNwnhacor.J.rr(oltccn*druNutftk,rhcG,nlmdolsLicensctl*).
<br />I nm.r.ml)l xnder s.clio
<br />uaBsDSl:.(auf[Nsa.rloN
<br />l)qcllnAuaN
<br />I hcrcby rltlr'nrndcr p.Mlry ofprrjuryonc ofrh. tulk,win8 d..la.rri,tris:
<br />I hr\t dxl will 'ninrain n C.n i.rrc ot C.tr$trr kr Sclf- lnsurc frtr $r)rkcs .onDcnslrion. is nmvd.n ,or hy Sccri{n, ]?m of rhc
<br />btxn Codc. for rhc p.rfortuncc of rh. woA for whi.h rhc pcrmn is kucd
<br />-lhrvcrnd
<br />willmainra workcn conlPcnsrriotr iNurrncc. as rcquirctl hySednnr.lT(x)ofrhc lih.rCodc. tor rhc r]cdornrncc o,
<br />ch M y {or[crr' .on'lf,nvrt,r i'rnmi.c. rirr 'W'-tsCaffi9J ( cl L
<br />1 4 l g
<br />I rcnify rhar in rhc Frformk. of rh. work lor whi.h rhk Frnir is i\\xdi. I shrll nor cmploy rny pcnotr in rny nxmrcr
<br />n, .{ (, b$o'E ubid ro tnc w{trtcrJ co rrcnsllio, laws of Calinmir, and asrcc lh.l il I should tEcom \ubjcd t, rh.
<br />workc* onllrdslrion pnrlsions ol'Setion 3?m oflhc tjtn. Cod..I shlll.lonhsilh oarply uirh th)r prcvisbhs
<br />WARNING: Fnilurc l{, Ecurc workcr( compcN'lion mlera8c is mlxetul. rnd rhrll srbjccr nn
<br />cnil fin.\ un ro,.n. I undrJ rhou\Jftl dullr\ 'llr}r.(In'. in r'lJtriqn 'u rhr (r!L',r (crtp.n\,/t..1
<br />,,," - $ /27ItY n*,,-;,)<l ,{( (-.
<br />I ICENSTD CONTRACT(}R
<br />DICIJIAIION
<br />.mpbr.r lo dimin{l Fmhics ond
<br />ion, domBcs as pmlidcd lor rhc
<br />I h.mby nflirn u.dd p.n.lry or pcrjury th{t I am liensd undc. pmvision of Clwlc! 9 (.ommncin8 qilh S(rbn 7ul0) orDivhk,.l
<br />.f $c Busincss rnd l,r.tcsionr Codc. rnd
<br />'ny
<br />li..ns ir in tuU ,orc. ud cffmr
<br />C t0 {l r)5
<br />z7 lts.
<br />CO! AUqI()NIINDINC.AAEACI
<br />I hcrcby uffirm undcr Fnalryolpcrjtrry rhar rheic h r con\rtucrion lcnding rg.n.y r.r rhc pcrlormmc olthc work tu which rhh pcrmjr n
<br />i\su.d (Sc..1097. Civ C.).
<br />AIIIICANLDECIABAIA!
<br />I hsltry lfm undcr Fnally ofpcrjury orc ollhe folh-in8 d(ltralions:
<br />Drnelirion Pcrnirr Ash.rros Norinc.rion Fcd.ful RcSularonq(Tirlc 40. Prn6)
<br />Rcquitod lrucr of Norifiurtun
<br />-l
<br />ccnilythlI rhc lcdcral rcsularions €sddin8 asbcsros rcmv.l arc nor applic lch rhis nmFial.-
<br />-'ffi-dn! hd t t-'c n,J thr rnplrd(nn ort {arc rld lhc,bovc inrornEtmn is cotrcct.I acE lo smply *ilh all ciryDnrl C.unry
<br />ordinanc.s rnd Sr,l. hwr mlnring robuilding conslflctnrn. old hcrcbyrulhorizc rctrcscnurilcs ofrhh Cirr rnd Counrrro ctrrn uF. rh.
<br />rla,v. ni{,Nl pr),)rnI lar insFcii{r,
<br />ADIliont o. AIenl Signntur:
<br />e"-ir* nrnr" rp"ino, {,/1 -l\ap M d42tp
<br />t Dd.i. Addrs
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