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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.OWNER DUILDER DEI,CARATX)N
<br />I hcr.by ar'ltrm uMc! pcnalry of pcrjury rh l on crcnfr l6m rhc Conks.lon Liccnrc hw lor lhc lollowin-g rcisrn lS(.7{].1 1 .5
<br />Busincs d Profesio. Cod.): Any Cirt or Counry whhh rcquncs 0 pcrmil ro c.n{rucl. alrci impruvc. d.molth nt renrt dny
<br />srocrlrc. prir b irr isx.rf,.. rho nquims lhc 0p id lor such lEn,it lo liL a lirncd iare@.r rhd he or sh. G liccnscd l,u6urnr
<br />ro rhc pbvhions of thc Conlrrctols t-iccn*d liw (Chaprs 9, Conmc..i'rF wirh Scction ?dro of Division :l or'tu susi.css tnd
<br />PmicssionsCod€)orrhlr hc orshe tcx.mpt rhcErrondnd rhc bdsis lu lhc allc-acd cicnprt,n Any viohrn,nofselhn?01,5 hy Bny
<br />dpplicrnr fu a pcrmil snbl..ls th. rpplic.nt lo a civil Fmlly of nol Ntrc IlDn fivc hundrcd dollrs ( $5ln)
<br />rvQatr[8ElaMtENsafloNDlcl.ln 0x
<br />I hcrcby nllirn uudcr NnrlryollErjuryom ofrhc folk,win8 dfthrarn,ns
<br />I h.vc md will mirllin ! Cenificltc of Conrenl h Scliln\urc (tr work.tr o,iqtcnsaliotr. as pevid.d f.r bt sdriotr lTO0ollhc
<br />Llhitr Codc, r.r lh. l)crform.cc of lhc work forvhich rhc Dcrnrir h hsncd
<br />-lh0veand
<br />will mainrain worlcs .onltrisanun in\xran.c. ns rcqutcd hy S(tion:1700 orrh. tjhor cbdc.lor lhc pcriomncc ot
<br />rhc sori finwhichliis pcnnir i\ issucd My qo.kcs' .onrrcn\alion insuraEc ert' dd B,lk! nun$.r ac
<br />Policy Nun$cr:-Erpncs
<br />Al ccdi ry
<br />'hJr
<br />in rh. pcrro Mmc of rhc !nr[ lor ] hich r hk pcrmir is i\\kd. I \h,ll nol c'ryloy ony pcso. io a.y frrtrcr
<br />G J\h bccnnF.LhE.r x'rhI *'trkc^.',nln.tr.tnnn luu( .1 C.l'loirnr. !1d agRrhar I \h, uld b..nn. \ubF!rrn lhc
<br />workcF conDcnsnrion rovisions orsc.rion]T0oofrhc Ltn Code.l shlll- lonhwirh c.mlly wnh thoB prolisions.
<br />W,rRNNc I'ilurc h e.urc sorkcr\
<br />civil lim( up ro otrc hunir.d rhotr\r
<br />sc.rion 3076 ol'lhc Lrhtr (i'dc. inrcrcn
<br />lrcagc is url,qtul. and shrll rufi]c.r M cn,pn,r$ ro di'niril Ftrrlri:s !ft1
<br />Xx)), in addn$tr h lhc co( ofconlp.n\rrn)n. drntrlcs .s rnivi{lcd f(n rh.
<br />'r/clt
<br />I]ECIJAIIION
<br />I hcrcbyaolroundc,Fo,lryorr.rjurylhnr I am lien$n undcr [ovhion of Chnpt.r 9 (.omtrn.in8 wilh Sdion ?OO0) orDivisk.3
<br />of lhc Busincss and PDfcsions Code, dd ny ,ic.ne h in rull lorcc Md .fioct
<br />r,t.r"cCr,,s,/ ts LI
<br />.bri Dectaa-t, lie,- T/za/rt
<br />CANJiIBUI.:IIANITNDIXIjIGINCI
<br />I hcNby t lnn undf ,rMlry o f pcrjury lhsr rhcrc h a.r,ndtu.ri.n kklnS a8crcy hr rhc pcrlonunr otrhc worl itr \'hich lhit Frnrir k
<br />istrcd (SN .tl)9?. Ci! C.)
<br />AITLICANI.D&CIdtrAtrON
<br />I h.n5y afiim undc. Fnalty of,'crjury om ot rhe folbwins drldnr ion*l
<br />o.mftion Pfimirr^sb.stos Norificariofl Fcdcrat Re8uhn,ns (Tirlc.{}, Pm6)
<br />RquiEd tins of NotiaEtion
<br />-l
<br />c.nilyrhsr rhc tcdcnlreulaltnF rcBrdins rshcslos rcnDv.l rrc norrptlic l. b rhispiojc.l
<br />-,ccnifyrh
<br />l hare rld rhis,mlicaliotr and (olc lhal thc ntFle informli.n ir.ond ll8relocomPlywilhallCiryrndCouhty
<br />oftlinxn..r rfJ Srrrc If,\\ kfirnip r.ildirRconn .liotr. a hcrcnyaurlF.irc rEpr.\.m,rilcs ofrhi( Ciry and Counry k, c cr urnrtE
<br />rh-vc trErriorcd nrolEdy ti,r
<br />ippli.nnt o. AE€nt SiAmlur.H".e l-rp<
<br />7/zclE
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER
<br />Translormers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Faclory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Sollit Rouqh
<br />Ceilinqs (T-Bar Rouoh)
<br />lvleter Release
<br />Rouoh 7-to "19 V"lult0
<br />Service lVleter x
<br />FINAL *-tt"tY r.'l4rd
<br />Notes, Remarks, Etc \J
<br />COMMENTS
<br />-1.
<br />as owncr of th€ ,,oFnr. or ny cnnloles wnh *!Cd ar rlfn arc drmpcnsriotr- will do thc worl ud ltE sMN is ml
<br />inrcndc{ or ollcEd ,o, sk lse.7o44, ausiess and Prolcssio.s Cod.: Ttc C.nrraclois LEcnse t2w d.as mr a$ly lo an osncr of
<br />rhc Imrcdy who h{itls or iqrcxs itosr, dd who des such s* hims.lf o! hcsclf or rtmlgh his or hcr ow..mpbyccs.
<br />pbvidcd rhar such inprcvcEnh N mr inrend.d or oltcrcd lor sak, li howcr.i lh ttrildir8 or imPmwmnl h sld {ithin onc ttr
<br />oa 6'npl€rion, rlE Owmr Buikn* Nill h0w rlE burdm of pmvitrE lh.l hc or slE did Bn ti{ild or iq,oE lhc pmp.ty lor Ih. PulPoe of
<br />-1,
<br />a\ o*ner or rh. F.Nnt. am cxclusiEly conhoclitrs eirh licctrsd conrt&rof ro d,nedcr lrt tmjcl (Scc 7Or4. Bu\ir(
<br />and PsfNiotr Codc: Thc Cotrxocror'i Liccnsc ljs docs nol aptlr ro uound olrrop.nywho tuildr or im!ruv.i rhcrmn.
<br />and aho s.r,e( ft, ch pr.jch wilh . ConlEdons) licctred puruanl lo rhc Contt.ror's Li.tnsc ljw).
<br />lamctunDt undcr scctron .B &PC f.' rh^ r.i.on
<br />D.t. O*ner
<br />kndci( Addr\s _
<br />tt
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