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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Bondinq i Groundino / 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 & Soffit Rouqh
<br />Ceilings (T-Bar Rough)
<br />lVleter Release
<br />Rough 7-76-tK \tlt)01
<br />Service lt/eter x.
<br />FINAL y2)-lV
<br />Notes Remarks Etc.
<br />OWNER BUTLDER DELCARATION
<br />I hcrc6, aflnflr lndcr pcnalry ot pcrjnry rhar I m ere ur from rhc Coitacron l-isn* tiw lbr rh. Lllo*itrB rcar. (Scc.7ol l .5
<br />Bu\in..\ {nd Prorcssion C.d.): Any Cily or Counry whkh rcqun * Fnnil ro onsrn'cl. .lrs, irymvLl dcmlhh or rcpot nn,
<br />srrDclurc,,,.hr ro irs iss,nrcc. aho rcqutesrhcapFlicanr ior suchtcmir Io iilc a\isned srarcft rhnr hcorshc b licc.scd punu&r
<br />k, rh. pmvisnns orrh. Conh,cror's Liccns.d bw (Chapr.r 9. C.mnf,kine *ilh Scclbn 70(O of Division I oi rhc tsusin.* and
<br />Prcfcssions Codc) or th h.orsncisercflrptlhcr.from,ndlh.bNklorIhcdlcscdcrcmplion Anylidario.ols..ri.n 70ll.5 byany
<br />appli.anl hrapcn.il subj(Is lhc applica to rcivilpcnrllyoltrol mrclhd livc blndrcd dolhri($500).
<br />l. !1 .wncr or rh. pmpcny, or my cmpb)rcs wirh wagcs as rhrn nnc conrrnsoi ion. will do llE vok {d rh. dMm i\ ftr
<br />inrcndcd or oficrcd for ele ( Sa.7044. Busines ud P,orcsions Codc Thr Conkrck*\ Liene t w docs nor lpply t, m o*mr or
<br />rhc pbpcny wlni boildsor nl{)orcs ltEm.. aid wh. d@s such $o.k hinNclfnr h.Mlf or rhmuSh his m hq oun crPl.yccs.
<br />pn,vidcd firr srch irpnrknrnrs m nor inrcndcd or oflaBl tur elc. Il, tn*rw. lh. ttrildiq o, in{'mtmnr t {kl uirhin oqw
<br />of corylclion. ltE {rncr Auildcr will lDrc rhc hrncn of!rclnE lh.l hc or shc dn nor l4iH or iipFts Oc poFny lor r pur}[$of
<br />_!. rs osner of rhc I'otrcny, u'n ckchsivcly .otuacring wnh li..nscd .onlhcror t, on\|fl.t tlE IrcJd ( S€c '7(X.1. Bu\inc{
<br />ind ftrlcstun Codc Thc Contractof s Liccnr. Low docs mr aml, l,) m owncr or trot ny who huilds or inrFovcs thcrean.
<br />rnJ who conrrack lor so.h tno}{h *irh, Cronrmro(rl li.cnscd rru(unt lo rhc L-onrruclnls Ltensc Liw)
<br />-l rn,rrutr,t, utr,l.r St.ri,)
<br />llsle O*..r
<br />worxq[s' coMi'rNs,trloit
<br />l)lcLASArlotr
<br />I hcrchy lffirn lMcr lcnrlr] ofpctjtrryon. ofrhc folbsing Jcclurions
<br />-l
<br />huvc and * ill mrirkin ! Ccnificlr€ of Con\cnr lo Scll ln\urc iu *orkoc .onl.n{rion, $ Fmvidcd for hy SNrion :l7u} oa rh€
<br />L$or O,ic, ror lhc l)crronu'Ec oflhc qort( for which rhc pcrnrn ir issucd
<br />lhrvc lnd*illtrrir Ji,,lvorkrrr compcnsrrnr in\r[n.c, rs rc!!i'.d bySL\ri ]r(X r ol r lr I -r$.r Codc, l'or th. F-nnrnin( oI
<br />rhc work lnr *hi.hrhi\ pcnnir i\ is{cd Mr- work.^ conlrn\arim in\rtun.c..ric, iurl |blict Nnrhlr ffc
<br />z l-
<br />I.cdify rhrl h rlr p.rlornsrc. ol rhc wo* (, lhah rht J)cnnn is n$cn- I \hrll nolcmnloy lny pcron in rny Dtrr$
<br />$ $ ro hcom subrd ro rhc rorkc6' conFnsrrion hrs of Calittrni!. and r!toc rhrr ir I rh)xld t.d,,* subjcd io rlE
<br />wo!ker('compcnsarionpovhnrnsotSec!ionl?molrhcl.lhtrCoJc.l\hll.fo hwirh.o'nflr qirh rho$ F,vi\ions.
<br />WARNINGT Frilurc ro KUrc workcs'conrFns ion covcrr8c is unhwtuI md filll \lhjcct cnpk,ysr b dirinrl Ftrrlics,trd
<br />.'vil fiics up ro ok hx,rdmd rhoutand d.lhs ($l(x).0o{l). ir rddniotr ro lhc cosl olcoarpcn\llion. drtuB.r ts P(,vidcd lirr lhc
<br />::ruq:k
<br />DIIIABAIION
<br />I ncrcbyamirnundcr pcnahy ol Frjurr rhll I am li.ensn und.! pmvisio. ofChaprgI (.odftfti.8 with Setb. ?0rO) ofDirhion l
<br />.l $. ausl.c* dd Pturcsb.s Codc. a ,ny lic.ns is in iull for.c a cfrrt.B /i.ao i Ll I 1,*,4 fun*/). >
<br />TOXSIBUqIIONIENDINC-AGENCI
<br />I hcrcby afirn undcr pcn,lry of p.iuly rh.r rhcrc is a @nslrucr ion hndirs accNy lor lne ptraormtc .r rh. w.rk lbr shich lhh pcmi n
<br />irsued (S.. l{}97. Civ C.)
<br />APILICANLITECLAAAIIAN
<br />lMydltrmundcr pcnahy of p€rrury on. orrhc f.llowins dc.ldarioii:
<br />D.molnion P.rmir$Asb.slos Notificdiotr F.dcral Rcgulolions (Tirlc 40. Pon6)
<br />-Rcquircd
<br />hncr of Nolilicolion
<br />1.&ilyrhrr rh. lrdrrxl ..!uhli,rs rcs n! r\h.{o\rrnxrrllr norqrfh.rl,lc i) rhi{ t'!,r^.r
<br />I &nifyih I hrvc r.rd rhisrptlicrr ionalt sr.rcrhal rh. at-vc informdi iscond la8reroconplywirhrllciryairlcoutrly
<br />ilding c.nslfl..otr rM hrrebyaurbrizc tprcEnldivcs oflhis Cily ond Counlylo ( c uF,.ltEo'di' n..s rnd Srrlc Iit*a rchr13
<br />at$rc mnriorcd proFny l{tr i[
<br />Appliunl trr AAMI SiEtr l
<br />4a /..2?t
<br />?/za/tt
<br />.EUm\
<br />Under Slab / Floor
<br />Lcndc.s Addrcs:
<br />-
<br />t ]
<br />I
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