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ELECTRICAL.INSPECTOR RECORD
<br />OWNER BUILDER DELCARAI'ION
<br />I hcrcby nmrm rndcr trn,hy or pcrjury rhar I ah .xcmpr rrch rh. G,ntrbr' Li.cnsc hw lor lhc lbllowin8 crsn lsa ?011.5
<br />Busincss !d Prcfcssi.n Codclr Any Ciry or Ct,utrry which rcqunc\ ! pcmn nr .on(rud, Dlrcr, impn,v.. dcnolirh oi rup,n any
<br />slrucrurc. tiir k, ns hsuancc.,ho mquircs rhc rppli.d' ror ruch FrmI ro nh i sigftd {rrcnrnr thrl lEor shc h lic.nrn lutruotrl
<br />ro rh. flovtions oI rhc Contocrols Ltcnscd ljw (Cfitrprcr 9. Connrcncins wirh Sccrn]n 7000 or Divhion I or(hc Busincss md
<br />Pd,r.sbns Coie) o. rhsr h. or sh. k ercfrlr rhchtrodand Ue hash t rhcsll.g.d.rcnfrnJn.AnyvioldlionofS(ion?03l5hynny
<br />$!lic.nl fo. ! p.flnil subjNk thc attlicantloacivrlpcnallyorn.lnnrcrh.nnvchundrcddollmlS5lD).
<br />l,.wncrolrhcpnlfnr..inry.n!!,rcc\wirhwascs!srhcir$[ronl|rnqrnnr,*illdorh.wu*andrtrnulurci\mr
<br />i cril&t or .frc6d tlr slc ( Sd.7oil,l. ausirE\s dnd Prcfc$ions c(iic: l hc Co mdol s t-iccnsc tiw docs nol olply r. on owner ol
<br />rhe pnrFny whohuildsori proks rhc6n, x'd who dms such w)* himkll or hc^elf or rhn,ogh hh or hcr osn cmtl,,)ucs.
<br />providcd rlrr such int,ovcrEnt arc nol inrcnlcd or aftrcd lor srlc li lN*.rcr. rhc t uil{lirg or i pms'mnr n v,U *irhir ', rc yu r
<br />ol conltlbhon. lhc Owrn Buildci*illhivcrhchud.nofpmvi'rg rlrl hcor\hrdil mt huild.r i prorc rhc Impcny for lhc pu.I,oE ot
<br />-1.
<br />nsowtrs of rh. fst nr, rmcrclu(irclycontdin8 wirh liNnrd co rncroF ro con(rud rtE rreicl (Ss 71X4, Bu\i"cs
<br />atul PDfssir Codc: Th. Conrra.kn s l-i.ctrsc Lnw dtrr no! lplly k, rno*n.r olprnp.ny tho builds or nnprcrcs rncrc.n.
<br />und who cont0cls ltr such rimjccrs qirh r Conhcrons) liccflscn punuanr
<br />'orhcConlB.ktr
<br />\ l-iccn{ lf,*l
<br />-l
<br />dncxcmfl undcr Scctio
<br />uaBxEEl:l:ollf[NlarloND[clrtBdllg!
<br />I lrrchyaf,l nutrdcr n nrlryof n nuryoic.l rhcfirllowinrdNl .rn)ns
<br />-lhircatrd
<br />willnDflrlaiD a Ccnificarc ofConsenr ro Sclr.lnsurcfor $orksr compensltion. N pmriddd tot byS(rhn:1700 ofrln
<br />Codc.lo! lhc NrLnMrcc oilhc work for qhichrhc!.nnit h hsucd.
<br />rl]{j wlllnrirllir *orle[ co'npcnsrri{nr ]tr{trincc. rs rcqrircdhySccri(r.lTmofrhcLrborCodc,larrhcNrbnnrf.col
<br />n i\sftd M,so c^ dnnplnqrion iNUr cc.aricr trlEili.y lnrhcrdc:
<br />aDlt
<br />l.cnifylhrl in rhc pcrfonNnccofrhc w.rk lnr which rhit p.nnir N isucd.l shrll trot cNployrny pcrson ir rny n,rn0rr
<br />$aslohcconrcsu$j(iloll'cworkcnc.rnpcnsrrionkwsofcslili,flri!.trrlrarccrhrriilshouldh.corcsuhP. orlf
<br />workcrs ompcnsalior pmvi\ioos oiSccrt,n]7&olrhc Latnr C(dc.l\tu'll. ronhwirh con{ly wirh rh.{ phvhions
<br />.ri1 ftr\ up n) om hrndrcd rhr)n\and dolln^ (sl(r).(xx)). in rJdirtritr nr rhc.on olco nsarion. damscs ns povidcd for rnc
<br />aIrr:6
<br />'I rv\l
<br />l )l.i t, \R \ tl{)\
<br />I hcrcbyanirm undcr rcnollyoapcduryrhJl I in liccns.i undcr lovhnnr ol Chaptcr 9 (conrEtins sirh s.dion 7tx[) ofDiviri.tr:]
<br />ol rhc Busifts ond Pmf.ssions Codc, od m, liccn$ t in full rb.e d ctld
<br />C-qro bg
<br />CONEIf,UI:IIOU.ENrIIG-AGEI(;I
<br />I iercby llil,n undcr Fnalryorp€rjury rhal rhcrc is a onntudion lcodirE asen.y lor rhc FrrortuRr.f rlf "ork for whtch thk tEmn k
<br />Gsucd (Scc. l0r)7, civ. C.J
<br />APIIICAIIDECLABAIIO!
<br />I hftl'y alrnn und$ Fn,hy of pcrjury om of rtE follouing dc.!e0l ions
<br />Dcmlirion Pcrn ri Asb.(os Norificarion Fcdnol Rcgnlarions (Tnb40, Pan6)
<br />-Rcqutcd
<br />Lcltcr of Nolilicorhn
<br />I c.dify rhxrrhc f.J.rrlrcgulrrion\ rclrnling r\bcdo\ rrnnnrlrrr nor t,flublck,rri!tr)i'.r
<br />irh,r I hivc rond rhnnmkarioratrd sdcrhn[hcahJrc i .nrrtrn,n h cotrccr I {ArLrroco,nrlr*irhnllCirv nd Cod ry
<br />. d srrh uas rlrlne roburld
<br />,\pDliutrl or ,\($t Siun lurr
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Founlains
<br />Signs (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq i UFER Qla-/g 4en
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinos (Hard & Sollit Rouoh
<br />Ceilings (T-Bar Rough)
<br />Meter Release
<br />Rough
<br />Service l\/eter -4L D\
<br />FINAL 521.t8,/24[.7
<br />Notes, Remarks Etc
<br />M ,{,,tt (4E
<br />hrcby rnr h. nzc rcprcic ililcs olrhh Ciry Md Counryr. €ntd uI.n rrr
<br />.," Y(l | (Y
<br />Communications Cable
<br />Air Conditioners
<br />WARNIN(;: Frihre t, rcud wolkcii rnnp.n$rl,n covcrgc is unlrtrful, Md shnll sub]l-rr rn cnrtlols to rininal Fnalrts lnd
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