|
APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<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 />Buildinq
<br />Bonding / Groundinq / UFER
<br />Translormers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />)
<br />Walls Conduit
<br />Walls Flou h
<br />;eeilings (Hard & Soflil Rouqh ,)t t UI
<br />' Ceilings (T-Bar Rough)
<br />lVleter Release
<br />I
<br />Rough taf loou v^{v,
<br />Service Meter {V I
<br />v|@tFINALlAto(8Tr 2.y
<br />Notes, Remarks, Etc..1-l74rt (8r U V
<br />OWNER BTJILI}Ef, DELCARi'ION
<br />I hcrchy amfln undcr pcmlty ol pcrjury rhd I am cx.trF fmrn rh. Conrrlos l-tetrc tiw ,or thc lollowindEv,n (sc.7l.ll5
<br />Bu\incss and Profcssion Codc): Any Ciry o, Counr, rhich rcquircs a ocmir ro con\rtocr. alrer, impnrv.. dcmlish or rpnn 0ny
<br />srfl.ruB. piorlo ns i*urn.c. d$ equt.! rhc rpplicrnr for \u.h pern b fiLn siBRd turcnE th.t hcor shc ii lien\cd purslnr
<br />h rhc trovhions oI rlE Connrroi\ Li.cnscd ljw (Chlprcr 9. ConrmkinE wirh sccttu. 71xx) of Division :l oI lhc Eurincss lnd
<br />Pmfcssionr C.dc) or rhd h.orshc is cx.mpr rh.rcar.o ld rhc hasn
<br />'l,
<br />rh 0llcecd cxcnUrion AnyviolnliotrofsariooT0.ll5n,uy
<br />,nlli.,trr r.r a F mil subr.cklh. rtllic,nl ro rcirilpcflrxyoinor morcth.n fivc huMrcndollm ($500).
<br />-1.
<br />!c owncr oI rhc !m,)cn). or my cmrlolccs wiri sllscr 6 rhct bk onFnsin,n, will d.' rhc *ofr and rtr s 1u ir nor
<br />idcndnl or ollcrc{l tor rdL (Sd 7044, Ausitu\s dnd korc*ions Cod.: Ih. C(r ncrols Li.cnse t-rwdocsnol orplyb{nosnerol
<br />rn. pnrrcny wh, huilds or imprors rhcNn- lllll who docs sucn w)* hin,scllor hc^clr.r rhdrgh hi\.r h.r.wn.nIloyc.s.
<br />tnvnbd rhar su.h imprEnEnlsmmt inrcnl\l oroficEd for slc lf. h.wctcr. rhc hilding or i.Dmrcmnr is sold *irh'n onc,r-rr
<br />of.onfklirn. rhr OeMr Auih.r will hrw ttE btni.. of!$vints rhrr tr or shc dil mt burld ar iq,rcrc lhc F,pcn, for rh.IrF)*of
<br />-1.
<br />ns.{trcr.l c pmpcny. .'n cxclNilcly contadin8 wirh liatred c.fin ron ro on(rucr ihc F+cr (S*.' 7or4. Bx.in.$
<br />,kl Pmfc\sio. Codc: Thc Contkror's l-i..ns. tru rloc\ tur rtnly t, owncr of|mn.aywho huilds or im!'rolcs lncrcoo.
<br />!!d Eho .onrads lor such p.sjccrs s ith a Conhcron n liccn*d pumulnrk'rheConrrrror'r t,iccnc ttrwr
<br />lanrcxcintr undcrscdidr Il & P C. hrrhirr.r\on
<br />I)rk O$ftr
<br />lloBliliBs:rQl.lfErsar]oN
<br />DE!:IT.BAI!I)!
<br />I hcr.hy illirrutrdc' rtrrdlly.tlrriwyonc.l ltu lilkNirr d..hrrridr\
<br />lhrvcd willnsinfuii i C.n ilt.r. of Cotr*nr tu S.lf lisurc tu rrrkd J- ..n$.n{r ion. $ nrovidcd tor hySdionlT(r)orrhc
<br />Llhor (i{lc. ir rhc nqfonMncc olrhc work for which rhc t--nnir is is\udd
<br />I luvc and will
<br />'nninrrin
<br />workcrf .o.rt tr$r n,n nnr kc. r\ rrquir.d hi Scdbtr l7m ol rhc litlor Codc. lor rtu pcrlorroncc of
<br />rhc qork rrshichrhis Frnrir i\ i\sudl Mywork.s .o fcn\nr ui Nurdn.c.nricr rMN,icy Nnrhcr arc
<br />*,r,.r'", -IZ -'rz tr1€4 a q-2s-q
<br />-l
<br />ccniir rhor in rhc prrl('rtu.c. otrhc wo,k tr shich rhn r.rnir t i\surd.l rhnll nor cmploy rny pt&n in a.y munrcr
<br />r, k h*onr sohjrr' ro rh. *olkcs comr.ns.rnnr h*\ or Calir(mi( rnd r8rc hlr if l should hccorc $hFcr t,
<br />'hcworkfi( co'nn ns,'io6povi\ionsofSccriotr 1700oirh. tjt$. aodc.l sh.ll. ionhwirnconrtnywirhrho\c provhions
<br />W]\nNINC l'iilurc lo sccurc \orkcn corDcnsdion covcrisc n unh{iul. nnd rhrll nrhject o cnthtci b $iNirll JEtrrhas trnd
<br />civil ,incs ut lo onc hundrcd rh.usand dollffi (.rlO0.(xx)). in rndnbn ro lhc co{ ot.onrpcn\nrion. danb8ct,s,rr.viacd htr rhc
<br />Sccrion 1076ofrhc tihor (odc. inrcresr ond oary s lccs
<br />Lr-?Z)'L2-
<br />DECIJNAIION
<br />I hcrcby lmrm under l)cnilryofpdrjury rh,r I a6liccnEd und.r provtion ol ch+t$ 9 (conrmNrns wilh Scctbn 7lx)O)oiDivnb 3
<br />of lhc Busincs$d Pole$n,nsCodc. ud lnyliccns. n ir rull torcc Bndcib.r
<br />"",,""a',r".&lb 2.a1e?-/-e
<br />,,,," G'2-?->-L8-ierrp EE6W lt-L-
<br />CONEIAIJI:UONJ,EIDINCIGINCI
<br />I hcmby am,n xnd.r Fnall, ol p.rjury lh.l lh.re is . .on(rudirn hndins o8ctry for lhe p.rforomc of thc wort ror shi.h $t tfm l is
<br />isskd (SE.1097. Civ. C )
<br />AIfUSANTIIiII,IISAIIAN
<br />I hcEty aflim lnder pcnulryolpcrjnry onc ofrhc rollowing dccl@rtuis:
<br />Dcmolition Pcrmih.Asbcsros Notilication Fedcrrl RcB!larions('lirle 40. Parr6)
<br />-Rc{uned
<br />L.rlcr ot Norificlrhn
<br />_l ccnif,rh rhc fcd.ral eguhrnns rcgddin8 asb.eo\ i.fl,v.l arc nor ryplicablc trr th( projccr
<br />lrcniryrhnrlh.vcr.ndrht.lnlic ion d s.rcrhd rhc.hrc infoflndi.n i\cond llgreiocomtrlysirhrllCiryrndcounry
<br />o'ditutr..\ r0 srrrr I r!\ rrlJ ins cotr(rlclio.. dfti herchyaulhorizc,ctrc{nr!rivcs orrhi\ Ciry,nd Countyi(, ctrlcr tr8,' lhc
<br />.hovc nrnriotrcd |n.If,ny lar
<br />Applic.nl or Irnl SiAtrtrlurc b-2$-B
<br />ELECTRICAL-INSPECTOR RECORD
<br />Under Slab / Floor
<br />iI
<br />i---+---
<br />I
|