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ELECTHICAL-INSPECTOB RECORD
<br />APPROVALS DATE tD/stG.COMMENTS o\tNiri atrrLDIiR DDLCAR TtoN
<br />I hcruby rfllrm und$ pcndly of prrjury rhor I m.rc,npl fnrfl rhc attrrEckn! Liccn{ ljw fi, rh. ft,lk,win8 rc.bn (Scc 70:ll 5
<br />aurincs d Prulcssion Codc) Any Cily or Counly wnich rcquircs 4 Fnrii kJ $n{fld. .llcr. i'nProvc. dcmlish .r ElIn lny
<br />srrucrurc, prktr ro irs is\uatui. ,lso r.quitu\ rhc lltlkdni .,tr \u.h ,rnnil ro filc a si8.cd (atcmnl lhal tE or slE i\ liccn*d p!*uanr
<br />to th. prcvnrns of rtr Co.rracrols Liccnscd tiw (Choflcr 9. Commncins *irh S..rn,n 7ffx) .f Division I of rhc Busirc$ lnd '
<br />ProfcsionsCodc)orlhalhcorshcirexenprrhcrelionandrhcbrsi\ntrrhc.llc!.d.r.mprion.AtryviohrionoiScclirn?0:ll5htony
<br />arplicanr nn,p€rmn suhjc(rhc appli.nmrorcivilF'ulryornot.rorcrhlnlivchundrc'ldolld\($500)
<br />-l.
<br />rs owncr oi l hc nripcny, (r dy cnrpl,'rtc\ wirh wrlcs !\ rhcn srb co rrcDsri r,n, sill do lhc work ud rhc dtulm i\ frn
<br />ini.ndcd.r.ffcicdfor$lc(Ssr01-r-Businc(udProfcsion\CodcThcConrn.ktr(Li(n\clirdo.snorrPnlyn).noqmrof
<br />rhc pDpcdy who brildl or nry'revcs rheron. s'xl wrm dms sch M, hnnrclforhcr{llorrhrou8hhnorhcro*ncqrk,!cc\.
<br />povidcd rhrr such iryro\nRnh m n, inr.nlcl or oftml for eh. Il h.$cwl rh. ltriHin8 or irymvemnr n \oU wirhir .nc ,ttu
<br />of.oryLrion, r Owncr Buiklcr pill haw rh. ${rdctr ol pming lhnl hc or shc did nol ttrild or irqrcvc rhc pn,ldy ro. d. pu{n* ol
<br />l.N.sNrorihc,,otcny.amcxclusivclyconrrcrinswirhliccnscdcobmbuhcons.[hcnmj.ttlScc7Or4.Btrsinc\\
<br />lrd hD[\sion Code Thc Cunhcntr s Licc.su Lrwdms nor appl,ro an owncr of proIcrl y $ho hnikl{.r inrrmvcs rhctcon.
<br />rnd Rho $ntru.h lbr such prcJc.h *irh a Co 6do(9liccnscd !0rsuln rorhcConlndor's Liccns. k*).
<br />I an.xcmpr rndcrSalion-, B. & P.C. aorrhh rcaso.
<br />(rPner
<br />uo8tr[SliawlNs raN
<br />Dr.cL SAllo!
<br />I hcrebyaflirtrrunderpLnrlryol|[rjtryoicolrtfolk)wii8dccl3nrn \:
<br />-lhnrcaidwillmuinrain!CcniiicricorConscnrrdS.lrlnstrrcrorworkcs
<br />conrl}cnsalion. as pmlidcd ftnbys.crionl?mollhc
<br />Libor Codc. for lhc pcrformoncc oflhc wort lo. *hich lhc pcrmil ic n\!cd
<br />lhrrctrnJ*ill'nainrrnrwDr*cra.otrr.ns ioDinnrdNc.r\.cqutL\lbySccrion.l?(nolrhctihorOdc.lorrhcn(nonrr€ol
<br />rhd wort f(n *hichrhi\ pdr n( rs hsucd My $orkcrJ .omNNInr insurnncccrdcr rnd polict nn rhcr rrc
<br />I ccnilirhlt ir rhcp:.lorm!nccofrhc *ork lor shichrhi\ pcrnrn is i*ucd,I shdll n.r cnDloyrnypcrv in any n trncr
<br />$ o!lo t$onE \uhjcd b rh. wo:lcB .orp.nralion hu{.rCrliLnir. nnd rFBc rlul il I \tn'uLt hcco'ft ruhi.r ro rlr
<br />*orker' !.mli€r\rlion nrcvision\ of Sccri(,n l?m of thc l-rhtr Gxlc. I shill. llnhsirh conDly wirh rhft Pmlkions .
<br />WARNING: Failurc lo $ rc *orkcn $nlPcn\ari,,n c.v.nBc is uilrwtul, md sh0ll subjd !n cmplortr ro aifrinrl pc alrics nnd
<br />.nil litr.\ up I' oN hutr,lr rhor\rtrd dollrrr rll{x).r)lx)). trr lldirrtrr (,drnBgrs r\ t(,!id.d li,r rh.
<br />Sccrion 1076.rrhc l,hn Cnrc. i cr.{,nJ,(onry s*", 7/tf/ tt
<br />DECI/AAIIII!
<br />I hcrby smrmu.dcr !.mlly of pcrjury th.l | !n nccnsd undcr povnion otCh!fld 9 (conmncing *th Salion ?000) ofDilhion:)
<br />of rhc Busi*ss and PrcLssi.nr Codc. 6rn my lic.ns. Ls in fuu foN ad clI(r.
<br />CANEIBICUS}NIBDIdO.&GEIiCI
<br />I h.rby dfirnundcr ltol(yofDcrNry lhal rhcrc N aon(ddion lcndin8 a-qcty for rhc Frormkc oflhc wort for *hth rhii Fmir n
<br />A t',.d is* .roc7. c'; c )
<br />'
<br />Lcndcis Addrcs:
<br />-
<br />AXTLICAXIIECI.Af,AIION
<br />I hr.by aEm xnd.i l.nakt or pcrjury ooc of lhc folloNi.B dccl"rii ions
<br />D.mni'bn Pcn.ih Asbc{.r Norirk.iion F.dchl Rcguld6ns (Tilc40. Pin6)
<br />Rcqiircd tf,td ol Noriamrion
<br />I ccnify Ihor lhc ltdcn l rcSu ht ions rcBardin8 aslEslos rcnnvrl!,r nolapplicrbk ro rhis pn,j.{r.
<br />I eniiyrhtrr I hNc rc.rlrhhapDlicaliotr!trd (!rcrhrrihcxtnrc ininhllnr G.or..r. r r8relocnmlly*irhallCiryrdd o)rnry
<br />odinrnccsn SrarcL{wsrchrin8rohuildiis.6nnrdn4edhcrbyaurhorizrctrcscnl0tivcs.flhisCiryandCornryroc rcruponthc
<br />T,-;LA444
<br />t /r<Ly
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER 3 7t (g <,tJ-q/,o
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilinqs (Hard & Soflit Rouqh
<br />Ceilings (T-Bar Rough)
<br />el .?$l 141@')
<br />Rough
<br />Service lVleter
<br />FINAL 3 l7 t/4 e50)
<br />Notes, Remarks, Etc
<br />1 bc t t.t.. It 1,,Wrrll
<br />Sile-Work
<br />Meter Release
<br />Policy Nln$cr:-Exrn s:
<br />-
<br />Lic.ns€ Chss
<br />-L
<br />icensc Nx,nb.rr
<br />-
<br />^, 1/<-<./rt .-**".{
<br />ah.Lr Nn'n
<br />'cd nn,n d) fur ur\ncgrionnurp".c\
<br />,lppricanror A*enr Srrmlrre A
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