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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNi]R BUILDTR DELCARATION
<br />I hcrty nfltm unds pcn ryolpcrjurrrharIamcxcmprfiornlhcContacknsLicenscLnwi(rrhcfol[,win*rcrs.(Sc.70]1.5
<br />Busincs aM Profcrsidr Codc): Atry City or O,unly which rcquias r Fnnil lo conslruct. rllcr. inrrrovc. &trx'hh "r rca0t !r,,
<br />slrucrurc, lrhr Io irs hsuamc. als lcquncsrhc amlic.d for such n mrirto,ik i siemd st.rcmnt rhar hcor nr h licdied p!^oanr
<br />to rh. ntuv(i.trs of rhc Contr.rm s l-iccns.d tiw (Chirrcr 9. Gnh!rcn.ing wnh Sccrion 7{XI} of Oivision 1 of rhc BusiNss and
<br />hofcsio ns Codc) or th8r tEorshc tcrcnrfl thcrcfmn,nd rhc btrsis lorrhcalk8cdcxcmplion AnyvinlorionotScclion?0ll.5byon,
<br />lppli.lnl forapcnnir suhjsls lhc amlicsnl ro!civilp.nahyolnol morclhan l'ivc hundrcddouur (Ssfi))
<br />-1.
<br />ac osNr ol rh. pmpcny. or my cnploles wirh aa!.s as rh.t v,lc .unptnsilnnr. Bill do lhc wMI and l,r nErurc h rel
<br />inrernH or ollcrcd for qk (Sa rolt. Busine$ and ftonsio.s Codc Tlr Coftacrois Lieoe titr d@s norlPply b rn o$m'.r
<br />rhc rblEny who boildi or impbvds rh.ren. .n<l sk, ilocs ruch s& hinNclf o! hcrcll or rhmugh his or hcr own c rrloyecs.
<br />providcd rhlr srch in{roknt.h m R inrended oroficrcd lb. n'lc ll ho*e!cr. rhc hrildin8 or inpmwmnr is s.ld silhin orc ,!!r
<br />olcoryLrhn. rtEOunq Suikhr sill havc rhc hurdetr olrovinE th lr or shc did
<br />'xn
<br />hikj or irytrovc rhc In)pcny rir rlr purpos of
<br />-l.asosE-rolthcri'pcny.!meiclusivclyconrrscrins$irhliccnscdconrra.tnt,.on{ddrhcprojc.r(s..704,1.8nvmssand F\Dlssbn Codc Thc cbntrackr'sLiccnsc Lrwdocs norllnlyt. movn.r olln)pcrlyNho huilds or imfrovcs rhcrco!-
<br />nnd who conrrlch rbr such ptr,jccrs wirh a Corrrrcron9 liccnrcd pusuanr ro rhc Conkacroir l-i.cns tawl
<br />_l ahcremrr lndcr Srcri
<br />MBrI&IrrOMfIiN$rA!
<br />IEIIAXAI]ON
<br />I hclchy xnhrund( I].nallyofFrjwyotu ofrhc Inlb{irE de.lrlri,nF
<br />-l
<br />hovc ud willminrlin s Ccnif'carc oiCon*nr ro Sclfltrsurcforworkcr'.o'npcnsatioo.as F)vid.d 16r bysccrion 3700 orrhc
<br />tibor Codc. lnr lhc,c omancc of rhc work for qhicl rhc l)cnnii h hsucd
<br />-i(i" ,,0 * r, ."tot *.rkcr' c.n{Fn\a,ion trFummc. os rcquircd by scrion l70o orrhc t,tx, Gde. rnr rh. Fyio.mn.. or
<br />lhc wnrk lhrwhEh'hr ncm rs n 'ud M) * nrk.r' omncn'r
<br />'on
<br />rn'urlne strin dd loli( y nuf,hfl m
<br />C/Vteas,'>
<br />3o
<br />-l
<br />ccdily rhar h rltr prrloirrsmc oitlr sork id whi.h rhn r.r.rir ^
<br />nsucd.l sh.llnor cmplor 6nypcron irlny nhnncr
<br />s s k' bcarnr subJ.rl lo lhc rorkcri comFDsal ion lflws oI Crlilor tri( and {3B rhur i, I \hould ttcont $bjcd n, rltr
<br />wortcr( $m|[trs.lion pmvniotr\ .1 Scction l7L{ollhe Lihor Codc.lshall.l'onhwirh comply wirh rh.$ provhiois
<br />wARNINC lirilurc n) rcurc *.rtcr onrpcnsdiur covcr.rc i\ trnl!$ltl. rtrd \hr1l suhrccr , .nrpl{,ycr t) sinrinal IE rhirs md
<br />civll rlnc\ u! ro onc hundred llmusaml dollm lsllx).(xx)). in idn[ion lo rhc con olcon]Ftrsrri.n. drmrsc\ rs tn,vidrd rd rh.
<br />Sc.run lr,76.rtdlf,bor C.d rcm
<br />"",",Sp/L<t.t( t.tNsliD c()Nt IIA( loR
<br />DECI,INAIDN
<br />I h.r.by aflirm undur pcnalry olr.rjuryrlur I {fr li.cn$d und.r ptuvisbn orChrpt.r 9 (corrErcing lith Scdtun ?Lt[) orDivnion ]
<br />of rhc Bosincsand Potc$ionsCodc, Ml mr liccosc n in tulllo!.! ud cfiLrr
<br />7z?44
<br />?/9 *.*"*
<br />CONuAIqIII.NIEIDINGIGENII
<br />I ncrcby dnnnulldcr p.n,h! ofr.rjury rhd thcrc ilr con{flclnn tnding r8cncy tu lhc rcrfonMncc ofrhc work tu whth rhh Fnnir h
<br />isslcd (s&. 3097, cie. c )
<br />txtr.lcr', NrrF
<br />Lcndcis Addrcss:
<br />-
<br />AITIICANI-UICLIXAII!}N
<br />I te$y nnirnr und.r p.irlryotp.ijury oft ofrh.lnlk'wntg dcLl,.r!iqr\
<br />Dcmlilt,n Permih A\tr(os Noriilc n,n Fedcml Rreulali.ns ('l ill.4l. Pnn6)
<br />Rcquircd I crrcrotNorilicrri{r
<br />I ccnLfythrr rhc ladLrrlr.8uLri.ns Nlddins a\b(nos rrnx,vrl rr nor l'ltlrahlc t, rhn pftic.t
<br />_l ccniay rhar I harc rcad rtis applisrion sJd sric rhar rhc atnE in,onrurion is cotrNr. I aEe t,.ory)ly wirh all cnylnd Coutrry
<br />n'J'nJft'c.riJSrrrli*\rlsri'.Ekturldrn8, nrtu(rion. md hcrch) rrrhn'nc 'ctr\ arr.!.1rh^C yMJ(.ulr) h' cntr,rn.r thcil:.:-^:":,il:'J"""p:z -,,*,/s
<br />Pcmi,een.m€,prin,,:,@' /hb-zzdF
<br />Site-Work
<br />Underground
<br />Light 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 / Grounding / UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Faclory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Flouoh
<br />Ceilings (T-Bar Rough)
<br />Ivleter Release
<br />t
<br />Rough I etulll& t 4,tpt*-,o/
<br />Service It/eter I ( (l
<br />FINAL ,t11vl llY trvary LA--''
<br />Notes, Remarks, Etc
<br />Pole Bases
<br />tz-
<br />I
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