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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrchy ltiirnr undcr p.nllry of p.rjury lh.l I {n.r.'nFr rmn rh. Cn racloa' Licnsc tiw for lhc followiry rc0sn (Scc.?01r.5
<br />Bosnrcs\ ind Proltsion Codc): Any Cil, o! Counry rhich Equncs 0 Fmn to conxlrucl. llter. improrc. &nolish o, ftpat any,
<br />{d.ruc, ri, t, ir* irsr,rcc. rlso rquircs rhc +plta.r ror \uch rEmir lo filc ! siEn.d d.ftnt rhd tr oi shc is liccned pusuo
<br />kr thc pmvnions of dr c'onlrocrois Liccn*d bw (Chapl.r 9, ComnrncinS wirh Scctnrn ?OD ot Divhnrn :l oflhc Busnr$ and
<br />ProlisionsCodc)orlhallrorshchexcmpllhcrcfnrann$ebasislbrlhcallcecdcxcnurlion.AnyviohttunotStri,nT0.ll5hyany
<br />,mlicanllorapcrmilsubjcclsrhcapnlicurlo0civilrcnoltyofnolNrcth!nfivchundrcddollars($50(,)
<br />-1,
<br />as owrcr o{ rhc pmtcny. or my cmflores rnh wnScr * rhcn elc .lmpcnsrrion. will do lhc w.rt rdltEshrlurc n nol
<br />ii cndcd or oficrcd for elc (Se.7Or4. Busircsr and Po,c$ions Codc: Ihe Conrractois l-icns U* doc\ nor ryp!, k, an .* nn or
<br />thc nmlEny vho boilds or irpmB rhcN)n. lrxl wh. d&s \kh Mi hnn\cltor hc6.lfor thou8h his or lEr osncmplorecs.
<br />Frdvidcd rtur \nch i'npmrnrnG at mr i cod.d or orlcrc'l ror eh. lt Iarwctu. rhc huilllin8 or irllprnEnE is mrd wirhin nm Jrr
<br />ol cohptclion. lhc Owncr Buildc. will h.rc rhc h{dcn ol prcving rhd h. or shc dil en hoil1 or im0olc rhc J'mpcny ror hc rurFE.I
<br />-l-
<br />asowncrofrhcproleny. !fl.xclusivclyco m.rin8 wii h liccnscd conrrudoF ro con{rucr rhc rmjc.r (S( 7ol4. Br\dc\s
<br />i, Pof6si,nCode: The Co.trc!{r\ Lic.nsc Ltrs docs nor upply ro en ound.fptup.ny sho builds or irnptuvus rhcrcon.
<br />and eho cotrrroch lbr iuch pmjcds wirh r Cotrrftto(9 liccnscd pursu.nr rorhcci)nrmcrolsLiccnsc Law)
<br />-l
<br />amcxcnu,t under Sdn,n-. B &PC lhrlhirrasotr
<br />]loa(fas:louxfrla-ultN
<br />Dlr!ir&r1laN
<br />I h.r.6y aifinundc! pcnolryoipcriuryorc ofrne i.lLBina dccl.nrio.s
<br />-l
<br />havcard will minr,in a Ccnificarc of Con$nl h S.lr.lnsuEr.r workm omDctrstiotr. ar u'vidcd for by Ssrion:170(, olrhc
<br />tihor Codc, for thc FrfornM.c olthc wo* lor which rhc p.,.nl is is\n.d.
<br />_l har and will minrain w.rkc6 conDensarnnr insuaNc. 0{ rcquic{ by Sccr ion lr({) of lhe tnhor Codc, ntr rh. p.dnne'u ol
<br />rhc $or( forwhichrhn pfmir is issed My*orkcc conrpcnsrri.tr insuEmcclrier lrxl polty nu.tEr sc:
<br />I ccnifyrhar nr rtu ncrlormne ot rhc aort lo whichlnh pcflnil i\ hsucd.l \hall noi cn'rn,ylnrF-^on in any'nntrn.r
<br />h Nroh.cum suhr..rr, rh.wo*. conlE.\rrio l,w\ of Cllifonir. md r8rud rhd ifI sh.uld trronf, subjd rottE
<br />*orkcn .onp.n\,ion pmeni,nsofScction 3?(Xlofrh. bt rCodc.l \hall. fonhuirhcotrlt'lt withrhor pmvtioni..
<br />WAiNIN(; Friluc ro sun s( .ri conrrcnurion cov.ragc i\ onhwtul. ind $rl! \ubjccr rn. lFk,rtr r. ai'nnul NMtics rtrd
<br />c l tltrcs ut td on. hundrc rhous..d dxlles ($lm.m,o), ii !o rhc.o{r or.onD.nsrion, daro8cs as providcd lor thc
<br />SNri.n:lo76.f rh.lih'ra..lc i' ..c( tr.J , lrmv'
<br />",,", ef ts f lc ^,,,*.,
<br />I tur.hy x,lir u .r F-mlry,'l ll.rjrt rhrr I rm lic.tr{Lt olChq,rcr9l$nnNn.i',gtrirhSrdin,?UxDol D^itil :l
<br />of rhc Businc$ md Pmfcsions Codc. md mylicctrsc is infu0 lnrcc!dcllccr
<br />czc:2j
<br />G tc /9
<br />l\!,.rlis.( lr)i)r ( i\ ( l
<br />APPLTCANT DFCI {RATII)N
<br />I My afiirm undcr pcnahyofpcrjuryonc orrhc followinS dcclarurions:
<br />Dcmlnion Pcrnt$Asb.(os Norifi.alion F.d$al R.guhrtuns (TirL40. Pd6)
<br />-Rqtuncd
<br />htrcrof Nolirr hn
<br />I rcniryrharlt tnc.rlr.guIrir)n\ rgxrlnr! rstr{os8trr)vrl)rc n.rrflrli. I r) rhn F)jocr
<br />I ccn,ryih lharc mtrdrhn qrplicrrn,i,rn $.om.r Ir8rrt,o \n\*irhrll(irvr ((iunry
<br />ordnEk.( a d Srarctlwsrlalin8 ro
<br />iti,lc tftntioned proFn, t6r inspcct
<br />Applienr or Ageol Sls@t!rc: _
<br />P€mllft nrm. (prlnl,:
<br />* ^". " "'::'';f)';f0""""
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool , Fountains
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Translormers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />Rough
<br />Service Meter ,.-1
<br />FINAL 6 .zr'{6 /,,{c z )
<br />Notes, Remarks, Etc
<br />Pole Bases
<br />Sions (monument)
<br />lVleter Release
<br />L.ndrt Ad&rs:
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