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ELECTRICAL.INSPECTOR HECORD
<br />APPROVALS DATE IDiSIG.COMMENTS OWNER BUILDEf, I'ELCA RATION
<br />I rf,rcb, amrn lndcr Ilc.alr, .f p€rj!ry rhar I d cxcnfl fFm rhc Cnntrb^ Li...* tlw for rh. followinB rclsn (S.c 70.11 5
<br />Busincss and Prof.isiun Codc): Any City or Coxmy which rcquirc( 3 lf,r ro on(fld. sXcr. inuovc, demlth nr ruI3t ,n,
<br />srucrurc. prio. to ns nsuancc. also requircsrhc amlicanr aor su.hFrnir ro nh o sismd (atcmnr rhar hc.rrh. ir licci*d N(ua
<br />ro rh. F,vi\n,ns otrhe Conkadoas Lisnrcd trw (Ch,flq 9, Connmncing wnh Sccrio. TtxD of Dirision I or lhc Blsincs lnd
<br />Pofc$ions Codc)orthd lIorshc n.r.mpl thcrcf !rndrhchasislnrthc0llc8cdcxcmplion AnyviolalionoiS€clion?0315hytri,
<br />applicont for a Fcnnir subj(lslhc opplicanl ro a.ivilpcMllyofnol nnrclhon lilc hundrcddolh6 (5500)
<br />I. ar owN 6f lhc lhFdr. m ny c,nplorr.\ wirh *rg.s as rhcn vnc .ompcnsrt,on. will do rhc wolk and lhc slMrm i\ B,
<br />inlcn ll or ofi.rcd li, sL ( se 1044. Susirc$ lnd Prefcsion\ CMcr l hc Conlractois Liensc Lio riocs nor apply '. atr osnr or
<br />rh.pmFny sk) hoildr or imporcs rlrED, srxl who dlB schw iins.lf or hcrslf or rhrcueh hn or hcr .wn cq'l.yccs.
<br />praridcd lhal such inDnwnrnls @ ml i"rcndct o. olIqld loreh lt ho*rrr rhc tniHing or imtmvcmm is $ki wirhh .N ,r
<br />ofo,npb'bn. rrr owncr Buil,cr will haw tE burdcn of roving rh{ h or shc di] ml build or impmrc lhe pmFriy ror rhc puqrr* or
<br />l. arown.rofrhctntcny, rDrcxclu\ivcly.ontruclihE wirh li.ctr{d .onrftcnn lo onnru.l rhc pnjucr(Scc 7(}44,3u\N\r
<br />rnd thrislb. Codc lh.Contacktr r t-icr \c l-aN doc\ nor atplyt, rno\ncr oftropc yshobulldsorimtrovcsrhc'con-
<br />{nd sho.onrdlrnsuchpmj.rls*irhrC.tr'm n(olicctrsdnunurnrrorheConrracroi\lic.n\cbw)
<br />I amcrmnr undcr S€rio
<br />llaAK!:lLsDlfENSiUlaX
<br />DECLA.SIIION
<br />I hcrcbtrllnnu d.r lcnnlryoflLrjuryon. ollhc lalk,$n{ dc.lardii r\
<br />-lhlvcrndwilliiuinlain!Ccnifi.atcolCotrsnrloSclf-Insurcnxworkc^
<br />conqEns.lion. us rovidcdforbySc.rnJnlT()().frh.
<br />hb.i Cod., f.i rh. Fifortumc ol rh. solk lor whih rhc p.rnrn n irsuc{
<br />,l hrlc.trd *illm.intrin $orken compcnsltiotr insurrncc. as rcquircd h, Sccri{nr]7O0.rrh. l/tx, (bd.. ror rhc pclfonmncc of
<br />rhc work rbr which this pcrnir i\ issEn M y sorkcn conD.nsal ion insururc. caric. ,nd pli.y nr frber m
<br />Pol'cyNumb.r i
<br />Xccn'ry rhr irrhc [Icrr.rmi.c orrh. $o nr whrhrhispc.mir is irsucd.lrhnll nol cmployinyocFon in anymanncr
<br />s\ rs ro ttsnr lublrr ro rhc trnrkcF cnnlI{nqrnn Lrw\orcalrf.rnn. arll8rc rh,r :fl \hnuu t{c.r* {bjn r t, rt
<br />workcB.onEtrssriohpmvhionsofSR_lion3?moirhcrjtnrCod..I.h.ll.forlhwilhconrpl,sirhrlDspmvi\nrns.
<br />WARNIN(; Irrilurc r, {.!r. *orkcrs con'tcnsnr(nr.o\r' gc a ln{llrl n ,l shxll nrhj..r r crnfkD.r b ninri'[lpcD]lri6 rntl
<br />Uvil lnic( trl) n, o r htr d'cd rhonsnntlrtrllrrs (ll(X).1)00r.i,nr. Jrnrgc\ Js nn,v .(l l,r rhc
<br />S.!r.i ll,7ii,,l'lr ttrhrC',,1r. trt'cq d rtfnry
<br />u!l!.!&tlt!
<br />I hcrchy rfln r uid$ Nnrlry of Ftury rhN I rr li..tql uMcr |ruvi\i(r .l ( hrt'lcr 9 ( connEncirg q irh S(rnrn XXX)) of Diri\n{ l
<br />ol rhc llusi'rs rnd Pnfc$ion\(id. rnd 'nvli.cnr i\ in full nnr Jrxic,fc.r
<br />Lts 8fr{tu@ Lba-og (])llttll-1l0rlal!}Li,!!r}!!
<br />I hercby ofinn undcr Fnally of rrrJury thlt lhsc i\ ! c,nsrrudhn kndins ilcty ror rh. pGroimmc of rh. work tor which ltis pcrmn is
<br />issucd (S.c.1097, Civ C.).
<br />AIIIICANLIECIABAIIO!
<br />I lrrl,y.trEn undn p.nalry ofI'ctury onc ol lhe lolbwin8 dcclanrions:
<br />Dcmlirion Prnirr Ash.{os Notillcation Fcd.r0l Rrgul ions (rirlc 40. P.n6)
<br />-Rcquncd
<br />kncr of Ndifi .arion
<br />I c.!ril.v rhxr rlr ltdr'rlroBtrlrn(na 'ctnkir! r\E((o\ rcfnrrlJc no! rt)l,li. hlr r) rlrN t)n,1.(r
<br />l.cnily rhrr I havc rcrd rhh.mlic.lionanl rhdrhcrhrvcinl'omrarionn.onccr Irgrl!hcomnly*irhrllCirynidCounry
<br />odimnccs nkl Sfurc tres rcLrriry Io buildnrg zc r.Ircrnhrilcs ofrhn c i aid counrt r) cnrd trF[ |lf,
<br />,t{u. 'nnr i.ftd f)p.ny tiir imtcrio,
<br />ftetar,*l6
<br />c2.,oI8
<br />Applicanl or ri*enl Signalut:
<br />l'cmilee mne lpdni): +q+@.EE-
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER {-211 v.tz$01
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soflit Rouoh
<br />Ceilinqs (T-Bar Rouoh)/A
<br />Meter Release i-2a-1tr \\u)a)
<br />Rough ,4.
<br />Service l\/eter ,V.tu)dZilHr -t (v
<br />Notes,R e m a r ks E tc.
<br />s(
<br />-\.
<br />Transformers
<br />FINAL ih.tlt)r
<br />"*,$vQ!P+?-
<br />(b
<br />2-o6
<br />I
<br />I
<br />I
<br />i-
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