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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG,COMMENTS owNEn BUILDER DELCARATIoN
<br />-=JI krcby .fiirm unJcr pcnalry of lcrjlry rhlt I .n cicmfl linm rhe Co.r6cr6' Lil.s tlw fo. rh. lollDwinS Ea$n (S..70315
<br />Buiih.ss and Prof$sion Col.l, Any Cn, or Counry *hich rcqun s a Frn r lo consrnEt. drci inDov.. dcfrnish or NIat any
<br />sldcluD. pflor to ne issudE, ltlo rquircs lhc q'di.dl htr such lemil lo nb a sistud srardr.i rha r dr 1h. is liu.nsd 0uNml
<br />to th. povrnons or lh. Conr&G s Li(ns.{ tiw (Ch.pts 9. Comnrtuins wirh Sccri,n 7Cr00 ol Dittn,n .l ol rh. Busims Md
<br />Pdtssions Codcr or rh.r tu or sh. is cxcnpt rhcr.tiom ud rhc hasn ,nr rhc allcscd €kehrrnn. Any violarioo ur Setion ?011.5 by,ny
<br />rtphanlr'o.arEmnsobjersrhe,ptli.anrrorcivill,crolryoliormftrhe6vchutulRddoll,s(gsU)).
<br />L .s osner nlrhc pn,perry. or fry.rtl(,y..s wnh w.!c\ as rhcn n,h onll].neron. silldD rtE q(,* anJ rhc rhdw n nn
<br />inIcntlal or oiicr.'l nr $b (Sa 7044. Bu\oc* rnJ ftolisr'!\ CoJd Th. C:onlm.nx s Liccn{ Law tj,rcs nol nptly 6 u owrc. ol
<br />rh.lnD.dy pho hu'lds or l,\}ovcs,h.Bnr rBl wlN d(s q'ehwtr* hinNllor hcnell or rhFDeh hii orncro*n cmtl,y.c\.
<br />F,vidcJ rhrr soch ihpn,!.n.nh m ,nn inrorl.J oi oli(rJ l!tr ah. Ia tx,wcvcr, rh. buruin! .r nrliovcnrnr x $Ll wihi" nnc ).r
<br />olilxryLrion, rhc O*ncr Buiu.r w'll Mvc rk burJ.n ol pn,vn,g rhrr lt or shc JiJ n{ huill or in\r,vc tlr !'n,ti<ny n)r rh. pnqrs oi
<br />I. rsown rofrhc ptu!.ny, ahcr.hsivclycD rlclir8 wih lrcnscd conrracl{s bondruct rhe pn+ct (Scc 704,,r. ausn.*
<br />anl Pnrlisiotr Cqlc:'thc Conrra.tr's t-icclsc L!* docs nor rpply ro m own.r otpol.dy who burlds or imp$vcs rhcrcon.
<br />and who.ontncblorsuchpnr)c.lspirhncofir.t.d9liccnscdl)unulnrbrh.o'n(r!ctn'sl,ifn$llw).
<br />I incKcnrpt u crSc.li,
<br />rv08tr!8E EG!rE!SAI!OX
<br />I2EQAAAIrcB
<br />I hcrcty a,i,munds Fnahyol!.rjury onc oilhc hlbwin3 dcclUaltr)n\:
<br />t havc .nd will mrinhin r Ccflnngrc ol Conscnr tr Sclllnsurc lor wolkcs conFft,rirn, $ ftuvid.d ror by Sc.tnr 1?0o ol thc
<br />bhor Cc\t . for rhc p.rfollMr of Ilf, ml* lu *heh rh. Idnnr $ ssuctl
<br />I hrvc rnJ vill mainrain work.( .on[.n\tuon
<br />'nsurrn(c.
<br />rs rc+ir.J hy S.ciion ]7110 nt rhc tjhor Ci)Jc,lrtr lhc pcnomrfrc ol
<br />rhc work n, whi.h rtur F-m!r r\,$uoi My*orkc^ ron,p.nuhon nrnr.n..lamcr nl F,lf,y .umbcr {e:
<br />I r.nrry rhat in rlE Frturnrn.c ollhc w.rk lnr wnah lhs p.rnrl k issucd. I shall nor cmpl(,y rny Pc^on in rny manmr
<br />n, rs k, hcsrm hJ.d b rhc w(n*.^ (rhp.nsdn)n hss oi Crlitum'a, anJ aBrcc rhlr rtl slnruu r.. om $,njd lorh.
<br />workc^ co.D.n\rrnlnptuvabn\DfSccrt lllo ol rlr Lh, c(rlc, I drll fonhwnh .omtly wrrh lh,B pnvnnrnr
<br />WAIiNINC: la urc 1,, sccu0 work.rs ronp.nr l. rnJ nrlL \uhl.(r rtr .n'dorcr k' .mriMl I{Nlk\ rtrd
<br />uilil ftrs trp lo onc hun,lrcn |h,,tr\and L! rhc r,N urlinr|cnqrnin, J,N8cs ls prnviJcl lnr rhc
<br />I h.rhy afttrm uodcr n nllly ol l,crjury rhal I im L.uhl undcr !r)vF$n oi Chaprcr t (onmNi.g wirh Sccrion 7000) or OivErn l
<br />of rh. Buu.s1 J Pdf.ssiorB CoJ., ,rxl my lk.n\. s n tull nrc and cIT.\l.
<br />a ,/o /32 o E
<br />, hcrchy a irm und.r Fcnalryol pcrjury rhr
<br />issudt (sc.. J097,Civ. C ).
<br />ii i{on(ruck'n hnJins ascncy ror rh. ,.nomnec ot rh. work br *hrh rhs lcm is
<br />^ttl& NI-DES! XrlflgN
<br />I lEtr+', dllm unJcr l}cnrlry or rtrrjury onc ol rhc li,&,wins JcclMri,'hs
<br />ocnknnr)n PcrnrrsAshc(os Noriricxri,r !in.ra1Rclularurs (l irlc,10, r'rn6)
<br />Rcqtrmd t llcrol Miili.iri'n
<br />thcltdclllrcSuhli('ns m3ndlrl3 !\hcn srcnxrvoluc nor au,lilable t lh! pn,rccr
<br />I havc rcld nrn appli,x.n (rrcrhrr rhcxh,vc hmrnr)n i\coftcr l dgr(r,c. rflywihlllCny Coutrrv
<br />connrutk,n. ml h.rchy rurh,rnc Epescntrhltr ofrhi\ City Md CDunly to cnlcr uF n tlE
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER i'l}}-^.^.
<br />Translormers 'u \
<br />Torqueing
<br />Sub-Panels
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilinqs (T-Bar Rouqh)
<br />Meter Release
<br />Rough
<br />Service lVleter
<br />FINAL v42/l tA'l-t-"o^..-.JD)
<br />Notes, Remarks, Etc.
<br />r?.,1t>ln f_P?)
<br />Air Conditioners Policy Nuhber:_Erpirs:
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<br />,^r"za1"//r?
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