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ELECTRICAL-INSPECTOR RECORD
<br />COMMENTSAPPROVALSDATE
<br />Site-Work
<br />Under round
<br />Pole Bases
<br />Li ht Standards
<br />S as, Pool, Fountains
<br />Si NS monument
<br />Life Sale /Low Volta e
<br />Fire Alarm / Dam ers
<br />Communications Cable
<br />Buildin
<br />Under Slab / Floor
<br />Bondin / UFER/ Groundin
<br />Transformers
<br />Sub-Panels
<br />Air Conditioners
<br />Roof To UI ment
<br />Fact Wired Unit
<br />Walls Rou h
<br />Ceilin Hard & Soflit Rou h
<br />Itrleter Release
<br />Rou h
<br />l,qnService It/eler
<br />Notes, Remarks, Etc.
<br />FINAL
<br />ol!Nuk Btrll,Dr:R Dlll,( ;\RATl(,N
<br />I ltrrcby afinh undcr p.nah, o, F4ury lhal I am ci.npr fmm rhe Conk,cttri Lf,cnB I:w ror ihc li'llo*ila rcaY'' lscc 7011 5
<br />Bu!,cs and Pmlesion CoJc): A,ry Cily or Coxmy which rcqltes I trmir ro con{dct. allcr. imoruvc, demrhh 'r rFn ov
<br />(rucxrc, pnor h ik isruMo., eho aqutrci th. imlaanr n)t sucl Frmil r{' rik a siSmd slrrcNnr rhdt h' or sh' ir Ii"nE! plrsri
<br />t, rhc |xsvisn F of rhc Conraclois Li.cn{d kw (Ch!Pr.r 9, G,mmctuitr3 *irh S&rion ?0U) ol Drvison I ol rh' Rtrsnc* rnJ
<br />P&l'cs\n'n\ ctdc) or rh,l hco.sn ir etf,pr UErcfron $d rhc h.ss ti,r rhc auc8.d crcmrrn'f, Anvvidrlonorseri'n70115bvanv
<br />iptl'.anr litr.ocmil sohjeck rhc apdicdtrrro Ic,vrlFnrhy01nor morc rlm nvc htn lr.d d.llaB (S5m)
<br />-1.
<br />!s oNn.r or rh. ptuIcny, or d cmtloyccs wilh $asd! 5 rh.tr sok .onFnsnuon will Jo rlf wo* a''l lhc inrtE ir nor
<br />inh .rl orolftrcd ar si (Sec.7or4, susircss D,l Prolc*tuns Cojc: Thc ai,.rracroi s Lmnslj*d(tcsfrn afl'lv t'} ao oMcr or
<br />thc ptrp.ny wtu hrild\ or in{,ovcs rh.Btr xnl who Jtr frn unk hrmscll or hcrscll or I hmugh hN or hcr own '6fk'vccs'p",im,r rl,"r .u"lr imldctrnk e ml hlcftldl or olIcdl ntr saL t,l hwcvcr. rhc buiLlnE or ml,l$vcmd n eU rirlin onc ,tt
<br />;rd,mplcri
<br />'n.
<br />rrr owi;r BuirJcr vill hah rhc tuftlcn o! F,viry lh.r hc .r rlr Jii tur ttriu or npdr $c nNFiv ntr lh' pnqr* or
<br />l. Nowncrorrhc pqr.ny. an.rclmrvcly.onrEdirrE wirh hcnscd c.nkrcloN k' uonnd.r rh. F)jccr (S'(' 704'l' Bu\incs
<br />,J PblissbnCo,lc:ih. conkkktr s Liccn\. L,w dds trol.ptly t, rn.wncr orprdp.nv sk' $uiut or rmprr!'r rhcRon'
<br />r d *l$ co krcrsntrs'.hpn)iccr\ wnhrCr')rtrr, h.ctrsci pu!\urnr rodLC,,nkrctr'\ Llcnrc l-rw)
<br />I nnc\.nq undcr Scdion-
<br />tI( l,Alr \t ()\
<br />I hcrcby.lT16 undcr p€nahyoip.iurydnc oiihc nnL,wing deLmlnlos:
<br />I hlvc anl will m'nlain r C.dili.arc or conscnl l0 Sclllnrurc lbr wort.c' onpcnsar nrn, al P$vicd lor hv S*rnr l?00 ot th'
<br />tibor Cixle. for llE ptrromEN ol lhc wort ror whi.h lhc P.mn ( krucd.
<br />I hiv. rnd w'll m.mrlin work.( contfnsdr)n rnnr
<br />rh. sork for whichthis o.mnr ,s,s\ucd Myworkc^'c(\3
<br />rcquiEJ by s&t ion l?l)o of rh. tjbor Ctdc. for thc tl.dnmn . 01
<br />il)n insu(afrc otri.r a&i policypmn r a.:
<br />(_) ,l^,
<br />e.(r
<br />l.cn rrhdr rihc pcnnrroncr (n lhc work lnr wh'chrhrsl)crmir ir tsu.J I drall nor cnll!)v .rrv pcron 'i'nvmann're, a( r, h.'rom suhJe(r h thc *orkcis, com|Ing.on lrws oi Crtit'hii utl lSEc rhd rf l should hc'oft suhic'r b rhc
<br />wolkcr ..mlcnsarbnpn,vreonsols..rion lT0Ool lhc l-ah, Culc.l drll. hnhw h.omPlv wir h rhok F)rh('n\
<br />IIARNINC: l'rlurc ni tct'. workcr\ lotrItns$(n,l. and \hxil suhic(t !n .nrdoycr n) oimnal Fndlrts mJ
<br />lhc con of.omp.Dslnln. dJnrlcs a\ P vd.,l Lr iftc,vil lincs up lo onc hrtulrcd thousan!
<br />S{rntr, ltr76dl rhc l- xtrC({1.
<br />I hcr6! ilTnrundcr pcnrhy o, Briury I trtulcr povsi(r oiChrpr.r 9 i$nrtucrcnl3 w h S.ddr]lx(,)olD^srnr
<br />.nsc $ n lirll ln(r rJkl clri.r.
<br />Del.-=-
<br />I h.trl,t rltu undcr p.nrlryolfnuryth,rlI k u,h$dcr6n,.nling.gcncy iot rht i.!'loanrnrc oirlt'wo.k li)rrhf,hrhl\ IErnril is
<br />$s'cJ (Scc .l0r)7. Civ. C )
<br />APPI ICANT DECLARATION
<br />I lErch, dtim undcr pc.alty oi ,criury onc of rhc tirllowing dc.lml ilns:
<br />ocfroliln,n Pcrnik-Ash.{os Noiiiicarn,n Fcd.rll Rcsuhn,ns ('I'illc 40 P!n6)
<br />Requtcd L.I.r of Noritiqii,n
<br />rr.nDlxlr nor rmlcrl,lc h rhr lmjc.'
<br />rhc ah)v. rrornDii,nr iscoftc.r.l asrcc b conrdy qih rll Ciry.ftl Counrv
<br />iitr, ui h.r.hy durh,iz. Etdscnrltircs ofrht cny ind Coury ro cnlcr u[r'nrh.
<br />'
<br />ID/SIG.
<br />4il*/n-/a-thd/l,
<br />Toroueinq
<br />Walls (Conduit)
<br />Ceilinqs (T-Bar Rouqh)
<br />0 -./'Ax/tt t h*zn- 1r
<br />1
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