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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE to/stG.OWNER BUII,DI]R DI:I,CARATION
<br />Ih$cb,rfilrnxnd.r,c.ahyolp.rjuryrhnrIn.x.dprf,o'nrhcc.otr.r.s'Li..ns.Lrwlnr$clollowinSrerenlS&:7031.5
<br />Busincs\ and Pror.ssion c{xlr)r Any Ciry or Coumy which drtutrcs r Fnnn lo con(rucr. .llcr. imtnvc. dcnolhh or rcron a;r
<br />strudurc. r,ior to ils isuarcc, also rcquncs lhc.mlicr for su.h pcnni ro nt r si8ned ({lcmnl lhal tror shc is liccnsd p!^!anl
<br />lo rhc povhiotrs.frt Co.!'acror's Liccnscd tjw (Chafr.r 9, Coinncmin! wirh Sccrio.7u00 ofDivision I ofrhc Busitrcss and
<br />lietcsions Codc) or thol hcor shc n excmpl rhcrc,iom and rhc,{(h torlhc alrc8cd cxcmprion An, vi.ldionors*rbn70ll5 by,ny
<br />nptlicad ror a F.nnlr subj(Is lhc rpFli.a.l ro acivilp.nalrr.rnor mftrhnn liv. hundrcddollrs (S50o).
<br />I. rs owturolrhc pn,p.dy- or nry ctntldit.\ airh s4cs as rhcir vnc lrnnFi\rri,n. will iL rtr $ork dt rhc sMur. i{ mt
<br />id..dcd or.fi.rcd for slc (S& ?04.,1, Busind$,nd Profc\\i('n\ Cdlc Thc C, ra.ktr s l-i.cns t.w docs nor apply to 0n nwrcr of
<br />rhc omltny wh. boilds or nnfiors rhcB)n. Md wh dc io.h trs* hnnrclfor hcFcllor rhrcugi his or hcr own cmplo]ccs.
<br />ptulidcd rhlr soch imFoEmnb e mr iorcndcn or olfcr]d lor $k. lrl hoscrci rhr hiui,rS or inlftuvcftd i\ $ld within onc re
<br />ofc.ry)lcrion. rhcO$rcr Bui crwillhav.rh.hurlcnoapDvin8rhllhcorsicdil b ikl or inpmvc rhc tn,rdy for rhc I[{Dc of
<br />_t, N owncr of rhc ,ropcny- ah crclosivcly conftdiry $iih licctrsJ co rr.t'A t. .rrn{tucr rhc prcjd ( Sft 70,14. 3unrc$
<br />(xl PiofcssFn Cod. ThcContrcror's Licctrsc tiw dmr n.r qrtlyt, anownd ol !i.t. y\rho huildsorimtmvcs rhcleon-
<br />rnd who conrrrls lor such pmjccrs sirh a Conrricu( n li(cnrd
<br />IIEIIAXd.III]N
<br />I hcrchy afirfl undcr lcnahyolpcoulyom ol rhc n,l['sin8 dlrllratnnr\]
<br />IhrveandNillroinrainrC.niicrr.ofCinhcnrt,Scllln\urcf{n(ork.^ con,tc \[ion,rr fn,!idcd f(tr bySc.rior ]7(Xl ofrhc
<br />lf,b.r Ci c. t{rlh.p.rtonunccotrhc *ork lbr uhict rlfFrnrit is is\ucd
<br />rhcworktur*hi.hrhi\p.nniri\i1\ucr!Nryworkcrf.o,trisrri{trii'NU'mcc.n'ricrntr(L|iri.ttrtruhcrflc:
<br />P"l'.y Nunber
<br />-
<br />!, bh(mr hj.dlorNw.rkcAconDc'sJri(rlx*\ol(i'llln'trirrn,lagn.rl rilI\horldh.rotrf,\uhtc.r1orhc
<br />{orkrri roDrp.tr\di.npi,rNiotr\olSc.rnnr:17(X)olrh.l]htr(i r.l\linll, ln'rhtrir[.. ]d!trnhrh.$!rovnio$
<br />1V RNING I'.ilurc to surc wmkcn comp.nsi'ion.ovcr(Bc is l,)!cr n).ri'ni"rl rnrlri.' rn,l
<br />,!rnm.\ r\ fn)rnl.d i(tr rh.civil fins up ro onc h!n,Icd thousrnd dollin lll(X).(XD), l hc.o{ olconrtEnsalion
<br />c:),(
<br />DECI,AEAIION
<br />I hcftby {flirm unds Fnrlrt dr p.rjxry rhar I r i li&n\dl undf Fovi<n orch Fr$ 9 i(nnnrn.rn8 *1h Sr_rion 7(DO) of Oivnion .l
<br />ot Ihe Bu\inc$lnd Prcfc*i.ns codc. lnd n,] liccn{ n in fullfua xnd.itcr
<br />ljaag&tcuqN!llltaclcIlg
<br />I hcrcby aonmuMcr p.nalry oi,,.rjury rhal lh.rc is s strsrfl.rir lc.din8 l8crct lor lhc pcriornEre ofrh. work for *nich lhn Fdn ia
<br />i$&d (se. 3097. Civ C )
<br />LcnJ.r'\ Namc
<br />-
<br />lxndci!Addr.s:
<br />-
<br />IITI,IIANLDIiILA.BAIION
<br />I lrrby rl]n rututc' Ffulry of |f,rjuiy on. or rhc l('lbw nE {lccl furi,rr
<br />l).nn)liri.n P.nnir\ A\hr{.s Norifi. rnn, Fotu'nl l{rgtrhrnnN ('l irlc.ll). I'd6)
<br />Rcqunc,l lxrrcr of N.rlfi crri('o
<br />(Jfi)4't' 'n",t" '"t*,t
<br />(8urJ,nrs m!,rd'ne d.h.q \nfr.vrrtr'.,,'{ '!'nrr$rc,u,h^ r,F,cc,
<br />/-\41ccrri! rhd Iha(rc rhn opnlEari.nud {drcrhd rhc atnrc irnruliotr tconccr I osr ro Nmply wirh dll Cily and Counry
<br />ordinrtrcs and Stnrcljws rcldin! robui ion. ut hcrcbyaulhorizc rctrcscnrarilcs oflhk Ciry and Counry
<br />rlxro Drtrri(rul t()p.ny tur iNp..rtr)
<br />.\ppli.nnr.rA!.nrSiBnntur. K
<br />n".-r".,,-" trr",,, K
<br />/J {
<br />Site-Work
<br />Unde rground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Satety /Low Voltage
<br />Fire Alarm / Dampers
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundino i UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditroners
<br />Roof To p Equipment
<br />Faclo ry Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilin gs (Hard & Sollit Rouqh
<br />Ceilings (T-Bar Rough)
<br />Itrleter Release
<br />Rough
<br />Service lt/eter /n\
<br />FINAL g,-?g{Y 8,W,1&.
<br />Notes. Remarks Etc
<br />-5
<br />COMMENTS
<br />Communications Cable
<br />Lr. \c Clx!\ I trrn\c Nunlr,
<br />Dalt (i,nlrnrl,,r
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