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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE IDiSIG,COMMENTS OWNOR BUILDER DEI-CAI{ATION
<br />I hcrcby aftrm undcr pcnalry ol r.rjury ihd I tun crcnq,t fmm rhc Co ,rclo6 Licene 14 i(t ih. rolloaidg rcr$n (Ss. 70-l l 5
<br />Burinc$ ann Pmtsion Codc): Ary Cily or Counry which Nquir$ r pcrmir r. condrucl. llrci imptovc. dc.blkh or rcI'In uny
<br />srruL1urc. |'trlo irs hsu!rcc. rlsorcqutes rhc aptlicanr for such r.nrn l. tucd \i8ncJ {arcmd rhil h.ot shc t liccnEd Putuanr
<br />k' rhc pmlisn,ns of rhc Contr.rofs l-iccn*d hw (Chrprci 9, ConnncncinS wilh Scction 7(xlo o, Division :l ofrhc Busincss ond
<br />Pdc$ionsCodc) orrh hcorshc tcxcmfl rncrcfronandlhcbasi\ ro,rhclll.ccd cx.'n[n,n. AnytiolathnofSsrhnT0:]l.th]any
<br />atpli.r r tu a pcnnn $bj*k rh. ryplicrtrr 'o
<br />0 civil rcn.lryornor nDrc th,n livc hundrcd dollos (5500)
<br />-1.
<br />0s owrcr nl rhc pmpcny, or nry cmpk,yccs ,irh wa8cs u\ rhcir $lc compctrvrnfl, sil] do 0E aor* ald lhc srrudud is mr
<br />imc .d oroficrcd f(trelc(Sd.7fi-4, Busincss.nd Prolcssions Codc: Thc Conh.tn\ Ltcisc ltrw docs not afi,lyro3no*ncrof
<br />rhc rmFny who toilds.r in{ftws rhcNn. dnd who d,rs ssh *or* hnlsclfor hcsclfor rhn,ulh hir or h.r o-ncmPbycci.
<br />nrovidcd rhar such irymvcmnrs m nor i' €rH or oftercd ror sah. !i hdftvci rhc building or irir,,orcmnl h soLl *irhin .nc lutr
<br />.r.ontlciirn. rh. o*nd BnikLr will h.rc tlE burd.n ol pn,ving rhd lE or she did not t[it or nnpr,rc lhc popdiy r.r rhc PurFsof
<br />l. u\own.rofrh. Jror.ny. ncxclusiv.ly.onrriins sir[ li(c.{nconta.ntr\xr.on(tu.rrhc nn}-.r (SL{ 7Or,1.8unncss
<br />and h,ris\hn (odc: Thc Conrrr.k, \ l-ic.n$ l-!w do.\ orrprlyn,rnoq croltr.p.nywhobnildsornn,'x,vc\lhcrcon.
<br />rid who.orHckr{trsudt)mjcchwirhrConknb(srliccr{dNrnaNrorhcConrlrroi\l-kcn\cLtr!)
<br />I an.xcnu undcr sNrion-. a. & PC.lirrhG rclsotr
<br />Drr.: Ownerl
<br />WORKF.q.S' COMPENSATTON
<br />DECtA.SAlrlN
<br />I h.tubyninrnunilcrp.n.llyofp.iuryorcolrhcioll.rin8d{l altutr\
<br />I havc rdwillnnri.r, r C.rrirrlre ofconscnr ro Sclllnsurc fn $orkcG corpcnsa'io..nr pn,vidcd lor byScclnrn 1700 olrhc
<br />Ldlltr Cod.. ror rhc pclornrM. or lhc work for rhich lhc t'mni i( nsucd
<br />-l
<br />havc!nd trillmi lin workcn comp.n\ari(,n insuBicc- N rcqun d hys..ton r7rx).frhc tihor CRlc. lbr rhc tii, rn'xm. .t
<br />rhc $ork lhrwhich rhhn mir i\ h\uLt Myw.rkc^ .oDpcnsrd iNumncccdricr ondrnlicynumh.r m:
<br />Al(d'ty rhnr m,hc ncrtomrft..lrhc \ork r4r Ehkh rhis r.rmir n issucd.l shall nor cmDb, o, pcron in nny nmror
<br />a. J\ ru trrom.uhrfl r, rhc qoAc6'.on'!.nsarrn tatr\ oladht"rnh. Jnd a!rc. rhJt ir I .lsuld h..r.N uhj.d ru rh.
<br />workcn .omr.ns ionttuvisions ofSetion STmofdc r:hor Codc,l sh3ll.lonhwirh L$nnly *irhrhos Pmvhions..
<br />IVARNINC: Frilurc ro Bcurc * .s onp(nsrrtrn' co!u,!c is u hsrul. ind shill i,hjcct orr.nubrcr t, Lri'ninrl |f,mlrics rnd
<br />riril lnr\ up ro oDc h ndrod rhou\rnd LtoLtr^Itn.fiXl). in dirion to rhc co\r ol.omFnsarioo. d,muEcs as pm\idcd njr thc
<br />,.7/zG/n
<br />PEIIdB{IION
<br />I hcnby alfirm undcr pcraly of!.rjurr lhll I am licetrsd undo provGien orch3pld 9(coltmmin8 with Ssrhn 7000) orDivni,n l
<br />ol $c ausiftsa.d P(n*sions Codc- md nyli.cn* n in tull lorccood€tf(r.
<br />f)t'1n{\r{ -"r(Dr c(1q-
<br />CANf,IBIJCIDNITNDINIi.&GE!3:I
<br />I hcrchya(nnundcr IENlry o l ncrjurr rl rhctuist.\rBrru.ri,nldndnr84cncyfotlhcp.rlhrnumcofrhcworkforwhthrhis,isnirh
<br />issucd (Scc. 3097,Civ C.).
<br />AIIUI:ANLDCCL$ DoN
<br />I hd!$y olfirnr uMcr nctralry ol!.rjury orc or rhc r(rlo*iix dcchrdii,n\
<br />Dcmolition PcrmnrAsh{o\ Norilic0li.tr ltdcral Rc8uhtions (l illc 40. P,n6)
<br />RcquncJ I crrcr ol Nnr'li(rr or
<br />l..dilyrhrrrh. LJcrrlrcgtrllron: rcEndirAr$.{o\ rd nvrl ir. f.l rfl]li.$lc t) rhi\ n.i+cr
<br />I.crrllyrhnr l h,vc r.nd rhi\ afDlidiur ml {ar.rhrlnrihivc itrnrn tr i\.oiiccr I rArcch.onrdy
<br />r d C.trdyni rnrd' trtr$rlr.onliniNcs ind sl,rc lissnbrir8 buildins.onsrruclion. ond hcrcby aulh.rilL !crr.
<br />$.1r nf, nrbncd prop.ny lnr
<br />Appli(unl or Agenl Sicn.tu
<br />/4qo klr 7/zc/r.t
<br />Site-Work
<br />Underground
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Lile Satety /Low Voltaqe
<br />Fire Alarm i Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondino / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rough)
<br />l\,4eter Release
<br />rA
<br />Rouqh 7-tu-/K XWtL)
<br />Service [t/eter A
<br />FINAL K-27-l{s,uv)
<br />Notes, Remarks, Etc.
<br />Pole Bases
<br />7Di
<br />Q,o!"t\'<\
<br />trtrdcr's Addrcs{
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