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ELECTRICAL.INSPECTOR RECORD
<br />OIINER BUILDER DELCARATION
<br />I herehy affim lndcr petulry of Frjury Uar I d crctufl iioh rh. O)nrrachR Li..isc hw ror rh. followin8 rcisn ( S( ?03 1.5
<br />Bx\inc\s and Protc$ion Cqiel Any Ciry or Ciunry which r.+nc\ r ,.r.ir lo .onshrr, alrcr. inpr.vc. dcnlrish or rcpan any
<br />drucrLft. prkt r. nt issuam€. als rcquncs thc dptlk.d for cu.h Frni b nlc I siSRd {alcm thrr hc or she i\ li.rn{d N^uanr
<br />lo rlE lrorhion. ofllE Conracl{r\ t-icen{d tjs lchrplcr 9. Co'nnrncing wirh sccii.6 ?ofl).r Divhion 3 oflhc Busrncs ana
<br />Pmf.s\nrn\Cndc)orrh3rh.orsh.hcx.r4rrh.r.frcndndlhrb.\hforlhcalll8encxcmplion.AnyvnnrlionofScctiDnT0ll5byany
<br />lpllica lnr.!.mil subjNts lnc a,,pliconr lo acivilpcnlltroanor morertanfile hundrcd douus ($50o).
<br />I.r owncrorrhctmpcny,ornrycnDnDrcswirhslgcsr\th.i'blccon{Enr n,n.willdothcwitrk dlhcnMnmis,Ft
<br />i cd.n orollcred lbr sle (Sa ?044. Bls]rc$ and thlc$ions Codc Ttc Conrt&rofs Li..n\c llw docs nor apply io anowrcrof
<br />rhcpNlrny eh. hu ild\ or impohs rhcmn. nid who d(*s such wnk himsclr oi hcr.lt or lhrou8h hh or ho o*n cnpl,yc.s.
<br />fovidcd rhar iu.h nnrrowmnrs arc nor inrcnhd d o,lcrcd f.r $h li fulw.wi rlE Soildir8 or in{rorcmnr is $ld sithin dic )tr
<br />of.onirleik n. rrr Osncr Buikld sill hrvc rh. burd.. of povin8 rtur h. or sh. dal frn tnikl or irinort rh. ptuFny lor lhe puryn{ ol'
<br />I. is o*n.r or rh. !op.rly. am exc,usirly .onlftlirg *ilh licctr*d conlrickrs lo mnsrnrd rrE ,arjd ( s.. 7()14. Buw$
<br />!n<l PDI$shn Cod. Thc CotrlEcntr's Liccnsc tiw do.s nor ryply to str ownd or rroNn y who bu ilds or iDrrovcs thcrco!-
<br />nnd who conrNh r(, su.h pmjels with 1 c], h.r.,ls) lkctr*d pununnrrolhcConrroclois Liccnsc l-aw)
<br />I imcxcnu utrdcr Sccrio
<br />tlaf,rEf,lrautElsar&a
<br />DECI'XAIION
<br />I hcrcby altnn undd F_nrlryofFrjuryonc ol lhc hlk,wnr! cclnrntiotr\
<br />-l
<br />hovc.fll *ill lMirrllin a CcniIEarc or G,nEnr roSclllnsutc ior worksa codr..sario., d\ polidcd ror bySc.lionl?O0ofrhc
<br />tjtrr cqlc, ln lh. l)fifonMmc ol tnc work rbr whi.h lhc pcnnn is isrued
<br />.\ralhlvc anl *rllmainrsin w'trtc 'c rFn$ri,,n Nuran.c. ,s (quncd by S.criotr 37m of lh€ Labor Codc. td rhc Fro'mnN ol
<br />lhc woil lor which rht pcmir is k cd. M, workdi dnlcnssrion insunnN cmicr afld lblicy numbq m:
<br />M to w kr r",.ne uv
<br />t?NvwCDl3lrqr o Ior
<br />I ccnify rhar in rhc pcrf.rmrm..lrhc work for which rhh r.nnil is i$uc!. I s[rll nnl cnlloy uy peBoi in rny mrni.r
<br />s a\ ro h.dJnr suhF.r h rhc so.kcs' conrrenstrlio. law\ ol Crlinmi0. lnd uErec rhll il I xh,xld ltooft uhjccr to thc
<br />*orkc^' cotrT.n$1n,. frcrnions ol SNrion 3rOJ of rhc L.bor Codc. I shil!. lonhwirh .uplt {irh rk'sd F,visions..
<br />NAR\lN(; l.rinir. r, {.urc rfr[L'\ o rf,n\rri,n,.o\r' !r ir unh\llL. r]d \lrnlln'hl..r if lorcr k, ai'ni'ulp.tulrio\ rid
<br />(i!il ln,r\ trt x, on. hundrd rhou\rn(l Jollrr\ r\lrX),(xX)r rugrs rs piovidcd ntr rh.
<br />Srcri(r.l(,76 o, r,r I rhn CoJc. i,[.rc{ r d ron
<br />011
<br />I hc'ul'r!fin undcr lcndryofFrjury rhd I m liLrnwl uid.r phvi{io. oiCluprcr 9(conrmncins uirh S€ri,n 7U$) oi Divisn,l
<br />ot rhc Ru\irrcs ond Profcsn'n\ Codc. dnd ntyliccn* i\ in full forcc drl clfccr
<br />cto Stqvttoit',iiT.^*4
<br />CONIiIBIJEIIONIDNDIIG.AGIiNCI
<br />I hcrchyomrnrundcr rctrrlryof pcrjrylh rhc'c irac.ndn,cri{,n k in8rs..yLrrhctnronMnccoflhc$orkitr*hichrhilrdnrirh
<br />rsucd (Sc. 1097. Civ C ).
<br />I rn,l.r'\ Ninr
<br />AITLICANLDECIAMIIAN
<br />I h.ntry dnnn undcr Fnan, of pcrjuy otrc ol rhc tolhqtrS dalmt ionsl
<br />Dcnolirion Pc.nns Arhedo{ Norillcario6 Fcdcnl RcBul0( b.a (Titlc .lo. Pan6r
<br />-Rcquted
<br />Lcncrof Norificark n
<br />l.cnifylhat rhc rcd$nl rcgul i{,n\ rcgodnrS osb.nos rcmovnl{rc nor qrplicrhL t, rhi" lnicd.
<br />lccn ly rhrr I hakrcrnrhi\ rpllicrri()nml {xr. rhJr llic rhirc ri( i\c.rNt I.greloconDlysnhrllCntdrdCo!trry./c rcFc{1'rrtrc' ntrlh air} rn'l c-Jnrt r,.nr.' uF{r rh'onli',xtr.c\ r Srrrc lr$\ rlrri',8
<br />dvnc nrDln,ncd nrorny r'or
<br />ADDli.nnl or A*6t Si*nal{rc (1 i
<br />APPROVALS ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lite Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Torqueing
<br />Sub-Panels
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rough)
<br />Ivleter Release
<br />Rough
<br />Service l\/eter
<br />FINAL q\21\g _<.t t(ti\
<br />Notes, Remarks, Etc
<br />8rrtni (*q u\5
<br />24 (
<br />DATE
<br />Translormers
<br />Air Conditioners
<br />I rnJ{',.4,1J,"..
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