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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUII,DER DDI,CARATION
<br />I hcmhy ,lfiro lndq lcnahy of Frjrry rhsl I !m .r.hpr Iro rhc Conlradtn l,t{.* lis nr rh. r.ll.sing rcrsn (S(.7o11.5
<br />Busirlcs ,nd Pof.srion Codc) Any Cily .r Coxnry lhich rcqut s a pcn ro .on{ru.'. rlrcr. tnprovc, d,.nrlkh or epan lnt
<br />nrucrurc. priorlo its nsu0nc.,oho rcqutcsltu amlica for such,xmir to fik, signcd ealcmnr rhal hcorshc n liccrrcd lurflonr
<br />h lhc trcvirions of tL Contra.roi r Li.cnscd Lr{ (Chlprcr 9. Commncing Nirh S..rtrn 7000 uf Diviion I of rhc ausinc$ ,nd
<br />Pn,lcssi(nr Cod.) or lh.l lEorslE hcxcnlpllhcrclronrrnd lh. b*is ror lh. dl lc8.d .rc mFl ion A.rviohlbtrolSclio.T0ll5hy{ny
<br />uprrlicrnl fo,!lcilnir suhrcchlhc omlicanl ro rcirilpcnolllollnx nmrclhan fivc hldrc dolhA (S5ml
<br />I. as owncr of rhr tioFdy. .r my cnfk'rtrs *irh slgcs ns lhcir w,l. comt \dn,n.silldoth.work nrl rh. Nnklurc i( rnr
<br />icfrlcd or ollercd Io, slc lsa.?0.1,1. ltusim$ and Pmlissions cdlc l'hc OJnriador's l.ic.tr{ tjq do.s tror mrly ro !! .wncr ot
<br />rhc |m,Fn, who huikh or impn,hr rhffi,i. md wtF dfts sch wdr tirscllnr hcrrlfor rhough hi\ orhfown cmPloyccs.
<br />,ovilcd rhrr srh inrn*c'tunhdcri, inlc rd orolIerd nr\rk ll h)q.vcr,rh hiklingornrymvc Enr ir hld wirhrnonc )rir
<br />oicon{,brnnr, rhc Owmr BuiH.i willhrlr rh. burdcn olrmvin8 rhd lr. or shc diJ nor huikl or iwrou rhc l}n)Fiy tor rhc llrIixc ol
<br />l. asowmroarhc pn,p.dy. d'ncr.lusiucly cont,.riig wilh li..i\rd.onrn'.rorsro consdci ltr rrojc.l lSE. 1044, Au{rc$
<br />and Pn,fc\si)n C.dc:1hc Conlractoir l-iccnsc l-rw docr mrrtply ro rn owncr ofl)lorcny $ho nuits o! implotrs rhcrcon.
<br />lnd who conrB.k for su.h pmj(k wnh i An ricklrl I ltciscd puruanr o rhc c(,ntackn r Liccnsc tiw )
<br />lnD crc rt, utrd$ Sc.
<br />4-tQ- zot*
<br />tlll-Bxrtss_.(0tlfrls -lll)x
<br />D[Clr-Bdugti
<br />-l
<br />hrvc andBill nEin'ain aCcnincarcoiConsnl to Sclilnsuic ror workcis conll'cnqlion. i\ fmvidcd tu by s(rn,n .r7lx) or rh.
<br />l,txtr Codc. for lhc llc lormrcc ol lhc *ork for shich rh. p.rmir h issucd
<br />I hrveand willnx'ir xin sorkcF c. ,tLtr!rri{D irsur ncc- $ rcquirc(lhySc.ri{nr.17(xrofrhc l-JhorC{,&. turrh. t^-nnnr! .rof
<br />r)t worl lnr Nhich lhis p.nnil i\ i\\ul\l Mt*.rtc (rnnr.rsrri,trr iNuranc. .xtric. lnd Frli.y nnnrbcr .
<br />- qaz4y 2!OO
<br />l.cniry rhnr in rh. p.rro.M,rc.frh. wo.k Lr *hich rhil F-rnir is i\srcd. I drll nnr cn{loy rny lanotr in 0ny nunct
<br />si shhcco,m hjcct ro rht *orkcs'conrcn i(,n h*s ofc.lifoa:ir. onn osrc rn{lil I rt uld hcc.m \ubjc.r io rtf,
<br />wolkqi ampcnnrti{,n prcvi\ions or Scdi,'n 3'700 ol'lhc hhtr Codc. I shrll. fonn(irh conrply $iih rrxxc pmvni,,.\
<br />\VARNIN(;: Iinilor t, s.u'c $orkcr\ onlpon\rrhn .o\rrr8c i\ utrlr\ln r \lrxll \rhjrd rnlplotrr (, dirnfrl]tmlri(! ntrLl
<br />civil lnr\ up r) onc hundr.d rhorutul do
<br />#K
<br />.o rnci\nri(rl drnxrgcs rr tr)!id.d li)r rh.
<br />Ia&"rit
<br />t.( t.\st;l) { ()\ lR \( lt)R
<br />DECLTNAION
<br />I hcrhrrfii u.d$ pcfulryofp.rjury rhd I rm licr{d undcr povi\i{,n ofCh.pld I (c.Nftn.ina wlh S(rr 7U)O) olDivisnr 3
<br />.f rhc Businrssrid l)roL\\nnrCodd. tL.d n,y liccnsc is i'r tulltrcc rftlcflicr4rffik 7'1b
<br />CONSIBIJCIIONIEIDAC.{GINCI
<br />I [cEby lmm undcr lcmxy oi pcrjury rhd lhtrc is a on{ru.lhn bndire oAcrcy for lhc pcrfo.m.nce oflhc work,(tr fii.h rhis F..rir h
<br />h{cd(Sdc :1097, Civ, C ).
<br />A.TILICAITIIEC].I3AIIA!
<br />I llr.$y aninn u Ms l)cnrlty ol pciury orc olrhe folk'$ing dcchBliotrs:
<br />Dc.xririotr Pc.inirs Asb.nos Norific,iotr FL'dcr.l RcSnlari.ns (Tirlc40. P.n6)
<br />-R.quicd
<br />l.c(cr ol Norilicoiion
<br />I rcnll,vrlrr rh.lidctul r.guhri,ins rclrrdi',g r\h.no\ r.nx,v l c n.rJJ,fL'.rbtu b rhn ti{)ic.r
<br />l..nifyrh l hrvc r.id rhis nmli.alnr rrl srrcrh rhc I rBrc tocomFlt Nirh allCirylnd Counry
<br />nlivcs oalhis Cny ond Counrlb enrcr urnn rhcrrdi',rnr.s JtrJ Srrrc l.rw\rhri"3
<br />rlhvc mmiorcn pn0.ny li,r
<br />Applicrnt or ,\!enl signnturc
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Qpas, Pool, Fountains
<br />Signs (monument)
<br />Lite Safe ty /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Bondinq / Groundino / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Roof Top Equipment
<br />Facto ry Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Solfit Rouqh
<br />Ceilings (T-Bar Rouqh)
<br />lMeler Release
<br />Rough
<br />Service lvleter
<br />FINAL 1 V.l{-it)'.vNotesRemarks, EtC.
<br />Under Slab / Floor
<br />Air Conditioners
<br />I hcrch, allnnr utrdcr ncnrlryol'r--rjwyonc ollhc tulhwirs dc.l{rdions:
<br />Lrtrdci\ Addrc$:
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<br />rI
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