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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BU!I,DDR DEI,CARATION
<br />I hficby affinn xndcr ,.nrlry df pcrjury lhd I m cxcmt r fnrm rhc Cl,ntucb^ Lic.n\e lis ftr rh. folL*inC rcas. (Sc.70]l 5
<br />Susinc$ ond Profc$ion Codc) Any City or Counry whi.h rcquirs r l)(ynrit ro .onsd.r. .lkr. inrrrcvc. dcmlnh or rcr,rn any
<br />(ru.ru(. priffb ir\ i\!u"kr, al$..qoncs rhc amlicanr tor su.h pcrn rlo nb & siBmd rrlrcmnr rhai hcor stc k licci*d n!^oair
<br />b rhc I,revhions oI lhc Conraclols l-icensc.l tr{ (Chaflq 9. Comnrctrcin8 sirh Scclior 7(x[ ol Divhion 3 of rhe 8u\inc$ and-
<br />I']bfcssn,N Codc)orrhrt hcorrh. is.rcmlr rl*rcFonand rhc I'a\h for rh.allc8sicrcnprirn AnrviohrionufS.di,nT0ll.5byatry
<br />ll)l)lic0trltu r pcflnil subjcck ihc lppli.anl ro ac*ilpcnnliyornor mtr. rhan llvc hundrc'ld.llds (S5u0).
<br />_1.!snwncrolrhcl)nrpcny.ornryc,q,lotccswirhu8csarrhctvnccoDcns nrn. will{lo thc*orknnd rhcsrturorc i\ r'r
<br />rnrcndcJ or off.r.d fr eL (SN.7()j4, Bxsituss dnd Profcssion\ Code 'fhc Cnntscktr { t-i..nsc lrw d<,cs hor llpl, b dn ownm of
<br />rhc pmFny who ttrilds or impmvcs thcmn. und who dcr such m& hnnscrlor h.rcll or ihmugh hk or hcr own cnllhyces.
<br />F)vidcdrhd ru.h impn,h'ftnhe n i.rcndcd ororLri lor sah ll. hoscvs. rhe hiklin8 or impmrgmnr is qrH *irhin om Fr
<br />oionplctiotr.thcOwmrBuilddwrllhrvcrhcburdc.fpmvin!rfisrhcnrshcdid,inhriu.ri'rprolcrhcpn,l.n,{orihcpurFie.r
<br />-l.,sowncrnlrh.tmpcny,
<br />amcxclusilclrconr0.linA wirh lic.tr*d ..ntr.to^
<br />'o
<br />cons'rud rlE f,oj.! (Scc 7(s,{. Bunnes
<br />d Ptuf6\ih Codc: Thc Conrrrckr's l-iccnse Lr* des nol lplly ro rn owrer oipropcrry who builds or ihpmlc\ rhcrcon.
<br />cnd wn..odm.tslorsuchpmjelswnh0GJntrucfttr(9li.rn{dt'uNudnrrorhcConk.cttrsLi.ctrstaw).
<br />-l
<br />inrcxcnrpl undcr S..l
<br />\t r)t{KERs ( ()Ntt)t.iNsAtl()N
<br />UIIJ lirllM,l
<br />I hcrcbyrf6rnrutrdcrp.tr kyol JrrturyoN.frhcn'lhwi'rgdcclrr,nns
<br />IhM.ndsill Dn ain,C--cnirrctrrc.lCon{nrrJS.lflnrurcf{trqork$i.u rr.i\rrion. r\ pdvdcd tnr byS(rt,i:lTUrofrh.
<br />tltltr c.Jc, ntr $r pcrfonmmc ofrhc *ork f{tr rhicll lhc p.flnil is isrucn
<br />-l
<br />h.vc rtrd$illnminlair $orkcm .onrrcns0rion ir$ra,f,c.,s rcquncd hySccllotr 37(x)ol lhc tjhor Codc.lorlhc pqio.nnncc oi
<br />lhc qork lor qhi.hrhispcnnir is (suct. Myworkns onlpcns,rtun insur.n.c .rricr .ft1 Flicy nu rhcr!rc:
<br />"
<br />-"*,/A /,/ \ o 82 o oa I o o /'f,-ct
<br />I ccnily rhrl in rt[- p.rfornwm olrhc work nn whah rhir !.nnir t,ssucd. I \hall mr.nrploy rtry Fr\on in nny mloNr
<br />$ !s ki hcorE suhjd rolhc *or*c^ conrrcnsaltun lawsolcrlifonria. und asrcclhrr irl rhuld tEconr $hl d t,rh.
<br />wortcrs con{cns(ion pn'visi,'ns olSdn,n ]T(]Oofltu Labr Codc.l lidhrviri c.rrply rvirh lhos Imvnions
<br />I\,\RNIN(;: Iirlr. n, \c.urr trorkc^ ro rt. \xlui I shrll sub^.r m cnrdoycr b .rimiml
<br />.ivil fitrr\ rt ro otrc huidr.d d
<br />,,,,,4'-,I
<br />.o{ ol .onlP.nsdn)n. drDuscs rs tros-ri.n ro7iin,h,' r "}."{-,"t,.
<br />7:1o-ao/
<br />I hcrbt rfiinn uMrr Nnrliyortrijury r lir.n\o uddI pi,)vntrnrolChrtld9(.onnrf,Nitr!rrhSc.ri($7Uxr)
<br />ol rh. Burnf,s\ dn Pn,tc\snri' Codc, ml ny ltcNr is i. t'll fuc rftljrcd
<br />c/o.ca .s<<8/J
<br />2 - /o-Ao/
<br />coNsralcu0NlldDllc-Ac!!.cr
<br />I her6, nlllrm und.r Fmky or pcrjury lhar rh.rc is a m.s crion lc.din8 og.my ror lhe ,.rfornecc or lhc work for rhich lhn IEmn t
<br />hsucn (Ss 1097,Civ. C ).
<br />ATPIIIAXIDECI,IISAIION
<br />I hsti, arm udcr pcnally of pcrjury om of thc folbwnrB d.rhr.l ions:
<br />D.mlitiotr P.rnits.Asb.rlos Norific0tion ltdcnl RCEUlolions Onb 40, PM6)
<br />Rcqun d Lrtro.f Norificarion
<br />-l
<br />ccnilylh.l rhc fcdcri I re3u l.l ions rc8adiru rstEi.s rcnmviltrrc n.rrfpli.nblc to lhh rnjcci
<br />l..niry rhd I hrlcrdndrhis rJ,rli..r i',lonmrnn i\.otu.r I rE'cc$coilFt{[hr lC[yrnd (intr y
<br />o,Jnrrtrrc\.trtrj Srr.l r(\r(lnri'rr n,lj h.rcby Nrhodc mprcscnrdnrr ot rhis Cily Md clruntyro cnlcr ug,n lhc
<br />ru Z6
<br />-
<br />"*",/y'QSo//
<br />Underqround
<br />Pole Bases
<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 />Transformers
<br />To uerng
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rough)
<br />[/eter Release
<br />Rou gh
<br />Service ltrleler
<br />FINAL fl/rt /ls a\*l
<br />Notes Remarks, Etc
<br />Site-Work
<br />L.ndcis Addrc*:
<br />-
<br />$urt rcirnnlcd ptu!.ny lnr
<br />F
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