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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 />S AS Pool, Fountains
<br />Siqnq (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding i Groundinq / UFER
<br />Transformers
<br />fqlqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rough)
<br />lVleter Release
<br />Rough fr2s/it tlJr'i
<br />Service lVleter
<br />FINAL 6f/4/,Y v\'{6
<br />Notes, Remarks Etc
<br />OWNER BTIILDER DELCARATION
<br />I hcrchy .iltn und.i pcnrlry of Frrury rhd I dr crnpr lbn rhc Conka.(tra Lacn{ Lde lor th. tofirwin3 r..vr 1S.( 7011 5
<br />Bu{n$s anii Prnison C,,lc): A y C y o! Counly qhr.h rcqutrcl r lrns to c.tr(nlul, alt(, impr'!c. Jcdntrh or qrtr rny
<br />!fl.xtr., prid t) irs 6 rhcc. nlso rcqun.s rh. llpl'c{nr l,n {'.h lf,rmirb fiL, silnclt nrr.ftnr rhar h.or sh. ! l,ccnscJ ttrrnml
<br />u rlE polisions oi lhe O,nrrrrroir Li.cnsa.l lnw (Chapr.r e, Conrmcn.ins wirh Sc.rirn ?m0 .i Divti.n I or rh. Busincs J
<br />Ptufc\si,n\ci.)urrharlrorshcL\c1.nprrherfroorJrhcha\ntu.rhcallce.dcr.mprn,n Any viohr nofS.cron70115bv.ny
<br />applicdl lnr { Icrm( suhjcB rlE aplli(rm k) . civrl pc.alry or nor norc rhd l r!. ntr Jrcd dollds ($5{)lr)
<br />LasowmroIrhcp$l.ny,ormy.mtLy€.rwhw,ecsa\rh.rn)kconlPrhsario.,willJo,.wrkarldrntufurcii,xn
<br />i.r.ftlcLl or oitred lbr sL (SN.?(}44, Bu$nc$ ."n Pmhrn'ns C.rtc: 'rh. Conrr.clni Licns. Lsw dcr nor {dy k, !n o*!cr oa
<br />lhr F'!.ny who t'uilds ur inporcs !h.N,n. airl who des su.h u,i. hims.lfor h.r{lfor rhdrlh hh or h.r dwncfrphy.es,
<br />F)vid.d rhat skh impn*.mnrs@ nol inkd.n oroliir.{ li)rslc.Il lnBrcr. rh. huillin! or imliruEmnr is hll wirhin orE fs
<br />of oonrpbton, rtr Owr Bui!.r will haw tlf, trhrcn or pn)vre rhxr h. or dr drl mt turll or lrlmrc rhc t,ntEry lhr rtr puqi,$ ol
<br />l. rs owmr ol rhc ptuIl{ny. !m crulNncly .otrlr.cr DB *[h hccnsc,l (n ncl(ns b uon(nr.l llrc tnucLr lscc. ?014. hKnc$
<br />and Pn,ft\\i'n C(xic: Thc ConrB.(r'\ I-(ensc l-!w d{rs nor apply b rnownc. oIn(,IEny wh' h'l'l\ or ihprott\ rh.rd)n.
<br />atr'l *ho !o nrrsktr$(hpn'J.uhw haC nrncro(srlr.nscJl)urruanlt'rh.Cnnlr&rttrst-iccnscLrw)
<br />-l
<br />r .r.,n trrl.r sc(noi . B. & l,c trtrlhr rcrnnr
<br />TOIKEBS:IOIIIENSAIION
<br />DECI.II3AIIA!
<br />I E(rchy rfltrnond.r F..k y or r(rjLry onc otrh. tullowiog d..ldaron\
<br />I hav. Md w 'll minrd,n . C.nitirdr. ol Con\cnr ro Scll:lnsu'c Iitr wtrk.B' $q,cns$on, ,s lnr!'dcd fttr byS.don l7(x) oflhc
<br />Uhtr Cr .. nr rlt Frfoturt. olrhc worl nr whrch rhc p.mrt ir n\!cd.
<br />_l hrvc and willnrinrirn workcr' uompcnsaron uantuncc,,s rcqurcd hyS.clon]?molrhcl-al,orCo!c. turdc p.d,trmin.. ot
<br />rh.workiitrwhi(hrhtpcflnirrstsucli.My*or[ccuomFsalionin{uanccu.ri(rd Fni.ynunhcra:
<br />Poli.y Nnmhcr:-h pirc\
<br />l.cdify thrl o thc p(rLrnrafrc (,fthr work Lr wh'ch rhn Frm,r n tr\u.J, I rhill norcmfkry rny ttNon in My r ncr
<br />$ b n$om $njal lo llrc uorkcls uomrcnsllM hws otc.liloiitri, MJ rere lhalirl sk)uLl bcB'm shjccr brlE
<br />workcr' .onrpcn\rr i,)n pn)vsons ol S&ton l?m ol rlE Lahtr C .lc. I \hill- rirnnwirl conrply wirh rhos rovnions
<br />WARNING: t'.rltrrc to \c.urc w(ficn onpctrsrri(,n cov.rafc,t tr hwrul. .nd shill suhjR. i m cnr oycr to trminil Fmlri.r irkl
<br />civrl lrncs up to onc hunllcJ thous,*l dollds
<br />sc.rk)n 1076 01 rh. lrhr(ixl. inr.,:-
<br />Df,(.:
<br />DEC! Bt!!!9.\.l pc,jury l lrar I an lu.\cd undcr rovron oi $rrh s.(Il,r ilrlr0) ol l)'r,\
<br />rxl n,y h.cn\. N n lilllnk! m,lr
<br />I h.rby xl tum un,icr lrnxX, ol Frjury
<br />F\ucJ (S.. 10e7. Crv C ).
<br />rh.rc ir n un(ru.ron hnJry rg.nry l;r rhc r-nnmrn.c ol ,r $.rk ntr *h(h rhA r--m,ir tr
<br />APPLICANT DECLARATION
<br />I rrnty,llim xod.r p.nahyolpcrjrryonc orrhc tullowin8 ilc(lualnus:
<br />Deholirion Perm(lAstcsros Noriltuarion rt'.lcrtrlR€EuL'ttr,ni (T lc 40. Pln6)
<br />-R.qumd
<br />tr cr of Ndfurtun
<br />r"",ir"\"
<br />trnJfl'\ A'lJrc.s
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