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ELECTBICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.OWNER AUILDER D!]I,CARATIoN
<br />I hcrehy aflno uidcr pcnalry or pcrjrry rhd I m cftmfl rnnn rh. c.trka.t(r{ t,ic.trr tiw ror lhc ioll.sina rca$n (Scc 70.11 5
<br />Busircss ind Prufcsn,n Codcr: Atry Cily or Coufly w[i.h rcquirc\ r rrnrir k' L-n{ ct. ,h.r. nnfmvc, d.mlhh i'r rcI)0n any
<br />nructurc. [iort, irs isuan.c. d$ rcqltc\rhc nppliconr [,r n'.hFdir n' fil.i signcd rd.nrdr rhd 1Iorshc iJ ]iccn:c.l prruanr
<br />t) rhc pn'vi\ions or rh C{n m.rtr's l-i.cnsl l-dq (chrlcr 9. c( nmncins sirh Sccltrn 70(n ol Divtion I orrhc Bxsinc$ nnd
<br />Profcsiotrsclodcr.rrntrr tEorshc i\ crcnlPr rhcrcnomondrhc hosn lor rhr ullcs.d dcnrrt'n Anyviol ionolsccriotr?illl.5byany
<br />atpli.nnr Lr !lcrmir \uhjsrsrhe npplictrnr b r.ivilltilhyol nor m)rrha fiv.hundrcddollr ($5Ul).
<br />L ri own$.rrh. ptuFjny. or nrycm/oy.cs wirh siSc\.s lhcn sot convrn\ornln. silldo ih. s,trk dftl rh. itu1trE h .ol
<br />i.rcfrlcd or ofiiEd tur {lc ( S(.7(s4- Busincs ud Pmi.\si,,n! C{!lc ]-hc (i r(t* s Lic.n* tiu docs tror rrlylo!nowneror
<br />rh. |m)ltny qho lrilds.r i'ryt)E( rtru)n. !d who d(B {Rh tr!* hitr$clfoi hcrclf or rhrcugn hi\ or h.ro{i cq)loycc$.
<br />prcvidc,l lhlr such irproy.m* u. ft i, (xlcd or ontEd for Ek Il h,kti ilf, hriunB or iNpmvcnEnr is bkl rirhin onc yctr
<br />or.o pkrri,n. rIf, own.r Buikkr will llrvc rhc $ordctr of pnrvnr8 rllu h. or sttr did nol ttrild or iolnn)t rhc ln,tdy lb. rhc Nrlrc oi
<br />l.,sow rrorrhcpn'nny.. cx.tusnclyco rudir8 wirh liccnscdc.nrocr{,\t,..niru.! rh. pro).{ rS(. ?04L DuMcss
<br />onn PmfssionCodc:lheCona(rnisl-iccnrcl-awdo.sn.rrpply'(,ano*crolprolcrrywhobuildsorimrr.ksrhdd,n.
<br />rnd *ho (,nhrrslor$rch!rurcckwirhaC.6rodsrliccnscrl,)unuanrrorhcConrackr'\Ltcn{tiv)
<br />I r.r dx.n,fl undcr SNri,rl
<br />Ircf,(lB au[!xs!.Iu!
<br />D[odaA.nor
<br />I hcrchyrfllrmu cr p.Mlryol tf,rry otrc ofrnc n]llnu inr dcclorlriinN:
<br />I halc,nd willm,inr,in ra'cnifi.dcofConscnrfu sclf-lnntrc lir *orlcr' comnrn\!rion. ar Fnvidrd for by sNUon l7tx) ol thc
<br />Lltnr Codc.li,r rhc plrfonEncc ofthc sork lar whi.h rlt lihlr t i*tr.d
<br />-lharcnM*illnri
<br />ninuorkcn c.mFn\ ion insDrlncc. rs E,luiEd by S(r i,,. l7m dr rhc libot (l'dc. a.r ltu pcrfo@cc.t
<br />lnc wort tu shich rhis Ennil il ttcrl My snrkcr o.rEnslri,'n in{n,n cMicr nl lolicy nu.rt c! m:
<br />Iccnilyrh.ri.lhcn onur.cofllrc sqk lor *hi.h lhi\ p.rmir is ir\ucd. I \hnll nor cnifloy rtry Dctson in 0ny mrnn.r
<br />v, k, bccom \uhjcd b rh. worlcB .onD.tr$rnin I qr.fcrlifonrid. rnd narc. rhrr ifl shukl hcco rc \uhFd rorhc
<br />Rorkr6.orIctr\rri,)nnn,$n)n\orScclion:lTmofrlrtrhorG)dc.l\hnll.fonhwirh.ondrwirhrho$lmvhiotr(
<br />WARNTNC: l'{ilMc ro sccurc rorkcn conrpcnrdiflr ovcrugc i\ ufl!trrtl, rtrd \hdll subjc.l rr) cnlrloycr to crinrinrl Fndl{i\ rnd
<br />civil litr.s up ro onc hundr.d rholslnd doUars ($l(
<br />Scction 10?6 of rl"a hbor Codc. i.icrcd and,iiomr'
<br />lrrie -,- - Applloblr
<br />iri. k, Ihc.on of cunlEnlnri(
<br />IECI,AMIIgN
<br />I lrrchy nflirn und.r lEndly ol lcrjury l hll I sm lien$d undcr Imrisn,n of Chnpr.r 9 (.ommn in! with SNlion T(]Olr) of Oiltion 3
<br />.r rhc aorincs ! d fr,r.sidnsCddc. md nrylicc.sc is i,r tullnmc flrd.[ccl
<br />c..,."",..{
<br />I hcrchy affim under pcn.lryofp.rjury rhdl rh6c h a drNfldhn hndin8 i8crct for lnc I'crlormamc olrhc wotk ror which rhis lEmil i,
<br />issued (Scc 109?. Civ C.).
<br />AfILICANLDESABAIIAN
<br />I hcr.ny alim lndcr rEnolry oa lcrju! on. .I lhr foli,winS ddladrkrns:
<br />Dcmolition Pcrnik-AstEsror Norificlrioo Fedc6l Rquhrion! (Iirle 40. Pd6r
<br />_Rcq!ircn lJrrer olNorifrElnn
<br />l.difyrhd rhr tudcral ftBrhrnrtrs e_8ailire rrhL{osr.nhvllnrc mr rpplicitrlc lo rhn pr+cr
<br />lccdirtrhd I hrrr rcrd rhi\ rt'tli.dtian.nds{crh rhcnt rr i.6nMi(r ncorcd I rgre io comtly sirh ,ll Cily akl Counry
<br />ordi'[ic.\ rtrd srd.litr\ rbrirS r) huildi
<br />rtxr. nrnriin,cd t0J^- t fitr i,Ntr.r
<br />ApDliunl or ,{lert Signalurc Vffi{o l"diTi;"r
<br />-\_
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundino / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Condilioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Sollit Rouqh
<br />Ceilinqs (T-Bar Rouqh)
<br />ltleter Belease
<br />Rough
<br />Service lVleter
<br />FINAL utiltk ,Kt
<br />Notes, Remarks, Etc
<br />COMMENTS
<br />Site-Work
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