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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />S pas, Pool, Fountains
<br />Siqns (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Translormers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Sollit Rouqh
<br />Ceilings (T-Bar Rough)
<br />Rough
<br />Service Itleter
<br />FINAL (?-tq -/6-J)eJo1z €g,
<br />Notes, Remarks, Etc.
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<br />OWNER BUILDER OELCARATION
<br />I hcrcby afftrn undcr pcndly of l)crjury lh0l I m cxcnDr from lhc O nr.clos Liccnss Uw for lhc followinS E $i ( s*.?0.1 1.5
<br />Business and Prcfcssiofl Codc): A.y Cily or Counly which rcqlncs o pcrmit Io $nndcr. allo, inpr.rt, dcnrlth .r mr6n /ny
<br />situcrurc- lrtrro ns issuance. (ho dtutes rhc dppliclnr l'or sucfi pcorir io lik r \igkd {xremnr rh,l lfor shc n liccn{d purso
<br />ro lhc lmvisioh of tlt Conlmctols Liccn*d tjv (Chnpr$ 9. Colnmcrcin8 wirh Scclion 7m0 of Divhion I of'h€ B8incss and
<br />Pro{c$ionsCode)orrhal hcorshc ncxcmpl thcrcfromlnd thct{sh inrlhc alLsedcicf,prion Anyviohridn.rs.cr-,.7011.5by!try
<br />appli.,ni rur a Fmir 3trbF.ts rhc lttli.anr ro a .ivil p.nalry or nor mr. rhM nvc hundrcd dolles (5500).
<br />-1.
<br />!\ osncr ot thc ,,n,IEny. or my cmrlorlcs *ilh wlges .s thct $lc compensrion. sill Jn Irt Mtt dd rhc (Mlurc i\ mr
<br />i.tolcd oroff.rd fin {lc (S1r.7044, Brsiftssand Fbf.sions C.dc Thc Cofta.rols Li.cnsc tiw docs nol qDly ro owncrot
<br />rhc Dmtcny wh. tDilds or iqroks rlrc@n, fld *ho &as fl.h {ork hin\cror hcisclfoi rhrough his or h$ owncmPloyccr.
<br />[,vnbd rh.r su.h inDmEmnB @ mt inrcfrhl or oltlEl ror sh ll ln'Mvcr, rhc t ilding or fi{'mlcmnr is n,b wnhin onc
<br />'t.rof.o fLrirn, rhr Owncr Build& will hr\c ih. hurdcn of ttuvin! rhd h. or chc did nor bnild or impr.$ fic pmpcny for lh€ lurFr of
<br />I. is.wncrorrhcpbncny. dn.r.lusiv.rrc.ntr,cring wirh ti.cn$l cofta.ro( ro conslnrcl rhc lmjccr (S( 7014. BNnc\\
<br />oln Pmfissi'n Codc: l'hc Conlrn lols l,iccnse L!* dms noi nDl,ly kr an o*ncr olpropcn! *ho huilds.r nnpmrcs rhcrcon.
<br />uDd who coiktrch for {.h pbjc.rr with d conb,cro(n li..n{d puruur turh.Co racLls Licctrsc l-Iw)
<br />IrlltstrE8S:l;OIIPJNSAIION
<br />DES.AAAIIQN
<br />I ncrcby flinm undcr pcnalty oa pcrjury om olrhc lollowin8 dchElions
<br />-l
<br />h.!c anl qill nEinroin a CenirEarc ot Con*nr ro Sclt lnsurc for worlsi mdpcnsdion. * f't,vnhd ror by Selion l?00 of lhc
<br />tnbor Codc. ior I lr pcfornurcc of rhc wo* for vhich rhc ,,crmil is issucd.
<br />I hak and vill .linrain *ork ra .on{rni,rion insuhr.. al nquircd by s(r ion l70o of thc bbo! Code- inr lhc F.nrmEne of
<br />r hc work for uhkh rhk ll.mh is isrucd. My workcis .omp.nsdion insur0mc .0niq ond policy flumt cr m:
<br />c,,i",, i {t'-e'--Y-{-
<br />-l.cnify
<br />rh.r in rrE pcrl'ornEkc ofrhe work tu *hth rhis plrnril is is\ucd. I shall nor cnrpby trny Fr\'n in.nt mrnncr
<br />{, a\r.tf,Lan* hjccr t'ih. *.rkc's..nDc s{i,ri hws or Cdlir.rnij. ldaBmih irIshould tEcodE suhjcd rollr
<br />Norkcr\.onFlsarn,nptr,vi\i.nsofSLdnrn.lT(l)ofrh.lrh)rC( c, l shdl, f(fihwirh .onrrly wirlr rho{ [ovisions
<br />wARNINc lalluc lo s.ctrrc q.rlcr conrpcnrrrion c.Eturc i\ ur[$inl. rnJ shrll suhj.cr a', cnitl{,yc. k, dnriMl Fmkiclt ,l
<br />civil incl up r. onc hundrcd rhousand
<br />\c.riotr lr)76 ol'rtu Litn (}d. inrcr.{
<br />".,",. ty'/4
<br />ddmts ds fovnhd ,or rlrc
<br />,fpptcrnr:X
<br />!2!i!r _8[L1r]r
<br />I h.hhyalfirmrnd.rp.nrltyofp.ijrryrharI rn li.en{d under ro!i\ n of Chll)lu 9 icomnrkinr sirh Scdion 7Lx)0) ol l)iv i\i{,tr .1
<br />ol rhc Busimsand Pmterlnnr Codc, ant n,y ltcnr t in tullttrc d.flicr
<br />L-to ?trt 7 32_t dr,&i fEtr,c>"qv
<br />I turch, alfnn und.. Fnahy ol pcrjlry rh thcrc t ! on$ru.rion lcndirs uscrcy for lhc Frformae{ or rh. work ror whi.h rht tmil n
<br />issucJ lslr l097.civ c)
<br />AELI:ANI.DIII,IBAIIQ!
<br />I turcryrnltuundcr p.mhy or p.'jory onc.frlr folkrring d.clanrirN
<br />DcN,lilion PcrnriIs.Ashc(os Nolificarn'n t'c{lcral Rcsuhrn'ns ('lillc40, Pd6)
<br />Itmu rc.| l..rrcrolNoliliurion
<br />I ccniry rhrr rh.rrd.rdeguldions rcBtrding $b.!os rc.bv,l irc ,ol atplicnhlc Io lfih lnFl
<br />Ll..'riyrh l rm\., drhn iprli.r,r
<br />ordnr Nc\ d srd.l JwstoLririr r,btriklr
<br />nl\corccr laerer.conrtrynirhrllCiryrndcounry
<br />horizc rcprcscnlalivcs of rhn (
<br />xivc nEninnrd prcFny f{n in\n cri,ni
<br />At,l,lit l o: ,\xu,l Six 'ntrtu K
<br />r,*-ir." -""" rp.i, , )(.-9o4
<br />^wf "'^;))'i)i""
<br />I
<br />lt/eter Release
<br />I rtrr.rn,tlund.r Sc(ri(trr .Il & | C lnr r[n rrr\trr
<br />lhr. ()*mr
<br />Lcndcis Addrc$:
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