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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.OWNER A(IILI'ER DELCARATION
<br />I h.rcby arfirn undcr pcnalrt ol lcrjury rhd I dr crcmrr ri.nr rh. C{ntdos Liccnsc L.* for lhc r'olk)Nin8,$son (Sec 7(Xl5
<br />Busnrc$ and Pnfc$ion Codc) Any Cily or Counly whicl r.qtrtcs r Frnrit lo con{tocr. rllcr. idrnrvc. dcnrlth or nlrt any
<br />nnctuq frint, irs hs!!tuc, ,l*, tuqondq rhd qrpli.anr li" such pcrmir lo iild r signcd shrcnE lh0l h.or shc is licctr*d pr$rnl
<br />ro rhe provnions of r,E Conlraclols Liccnscd LnB (Chalrcr 9. ComnEncin8 wirh Se.rion 7000 ot Oilhion :r or rh. Bn.in.is md
<br />Prctcs\io"s Codc) or Ihar t or \h. n crcqrr rhcnliom ud rhe n!\n for rhc allcsed dc6pibn A.yvid,rionorscclion?031.5$yotry
<br />rrpli.a.( for n p.nhn subjdis rhc imliuanr roaciv,lr.mhr.rnor nrrc atr nv. hunnrcn dolds lss(x))
<br />l.ssowm'oirhcpmpeny.ormycnttl.yr.\sirh$!gc\orrhcnvnc.ohpcissr n.wrlldorh.wortu rh.sMrurcismt
<br />idcndcd or ofcr.d f(tr slc (Sm ?O14. Busrncs and ftofcsidN C.d.r Thc (bnlr.dols Liccnsc tja docs nor aml, to !i owkrof
<br />rhc lmpcny who boil.h or init.ors tld([ md wk' do$ !u.i m't( timscllor hcm.ll.r rlrough his or hcr own cnDlorcc\,
<br />p.olidcd rhnl such inlnKnrnh aN nor i.rcndcd oroficNl forsh ll howcvcr. rh!t{iuin8orirn mv€Enr is sld *irhin ond ttar
<br />of corrhtir. rhc Ownd BuikLr will hsw rh. burd.n df l)ro!in3 rhd hc .' qh. did mr buikl or iqmrr rh. pmFny for tlE pu4Ds oI
<br />-1.
<br />rso*ncrofrhcrmr'.ny. amcxclu\ivcly.onrodins $irh licctrs conrBcro r. connrud rrE projccr (Scc 7or4,8u{nc(\
<br />m.t Ptr,fcssin Codc ThcCoorEcttr'r Licri\c l-rwrhcs norllplyt, !nosn.r ufrrotrdy who buildsor iDrroves thcrcon.
<br />ntrd who .onr.r.a rd su.h pn&cls s h d Lnntrudo( n li.rn*d nu ur hrthcO)nrrrroisLiccnscLuwt.
<br />-l
<br />amexemfl undcr S€crio
<br />ltaBr};E,rroMfENs/IIl9!
<br />DIS,AAAII)N
<br />I hcrcby liinn undcr FnrhyolFrulyooc ol rh.lollowine d$l(!ln,n\
<br />-lhaveudsillnuintlin!CeniarclrcolCon\cnrroScllltrsurcrbrworkcn
<br />cotrDcn\riidras !(,!idcdldbysccrninSTmolrhc
<br />Iihor Codc. f.r rhc lcrfomncc ollne work nn rhich rhc lcirnil h k cd.
<br />I hrlc and Ritl nuinrrnr wnrk.r\ .o rr. Ndi(n insurr .., a\ rcqu nd hl S..ri,)n :lr(x) of rhc lrlu Codc. lor lhc rtlnnNN. of
<br />rhc srtrk for whi.h rln\ Nflnn is i$udl Mt *orkcs c.nD.i\ ir'i ir$rrmc .rr icr rtu Flicy nu Nhcr fl c:
<br />-l.cniiy
<br />rhrl h rhc pcrioruEe.flh. sork l'or shich rhn pcrmil ir h$cd. I shlll mr enpb! rny pcr{n' in any n'Mmr
<br />q) r\ ro b...nr sobj.d h rhc q mk.B .n rtf,isdnrn hss of Crliirnix. a.d +re thd il I \lrculd h.onrc \uhlcn to lic
<br />qorkcA comp.nsarion pmlisn,is ofSc.ri,[.]7(Oofrhc Lahn Codc.ldull, r(nrh*iih ..nrtly wirhrh.* lrovisiors
<br />IVARNINC] l'rilurc ro ccu.c aorkcn co Dcns.tiotr covcruc is nnlo$tu|. ond sholl suhi.r an cnlPnDs b cnni'ul t^-nrh.s rnd
<br />dlmgr\ r\ tnrid(d f({ rhtcivil fincs W to otrc hundrcd lhoustrd o
<br />S..ri.n ll176 ofrhc I alnr Codc inr.r.d !nd,^,.,4fi1t g
<br />r-{
<br />I hcrby drr undcrFnrhy.rrr.rjuryrhar I m li.cnrd under Imlisi.n of Chapt.r 9 (commncirg wilhScclionTOOO) ol Divnnnr S
<br />ol ihc tsusinc$md PmltsionsC.dc- and Dry liccDre t nr tullture! clltcr
<br />4 U
<br />Alt;fiB ,-,*"-X. )ffr-, T'^.t
<br />CANIIf,UIIII.}XI.ENIUNU.&CENCI
<br />I hcEhJ" aflrnrntui p.n,hyor,,.!uryrhar lh.rc i\ a$n{d.riJn Lndin! r!.n.y nx rhc r.rtbrnuncc ofrh. 'ork lbr $hich rhi\ ricrnir i\
<br />issulrl{sa l(y,7, civ. c )
<br />APPLICANT DACLAIATI(}N
<br />I hdll'y altim un&r Fnoli y of pcrju.y orc of lh. following delmlionsl
<br />DcmrionP.imirs Arb.{os Norificerion Fcicnl R.gubrions (Tnb40, Pnd6)
<br />Rcqnimd knfi ol Noliarolion
<br />-l
<br />ccnifylhd rhc ltdcrol rc8ulolions E8irdin8 lsbcslos rcnmvrlir. nol rulicrblc ro lhn projecr
<br />_l c.nityrhir I havc rclnrnis amltart,na,{l srtrrcrhar ihc ltnvc irn'nr i\ (md I aFft t,.$ Dly wnh all City nnd Coutrr!
<br />onlininc$ ond Srdc Lrw( rhinp ro buildinp co.srruc1
<br />&hovc rrcnridNd tm,lcay tu inspccrmpuqucs.
<br />Aouli.nnl or !€nt sirnxrureX.
<br />,"-U* no-",rnn,,,X Dz6- N*rE^)
<br />'ffili
<br />Site-Work
<br />Unde rground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltage
<br />Fire Alarm / Dam pers
<br />Building
<br />Under Slab / Floor
<br />Bo nding/Groundinq/UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Bouoh)
<br />Ceilinqs (Hard & Soflit Rouoh
<br />Ceilings (T-Bar flough)I
<br />Meter Release lfyyf ,P I a1,..]'/'^-4L
<br />Rough tpl,}ltr -s t$rre*1.7,a)
<br />Service l\,4eter r{r
<br />I
<br />FINAL t,l LAAE,4 e-r/
<br />Notes, Remarks, Etc t uI
<br />--)
<br />COMMENTS
<br />t:,"",' GilJPrQD :r.{g
<br />o,,u.r*",*".' DArXrzr. 884:7 7 / n.,,,,".
<br />Dfr-
<br />Communications Cable
<br />Air Conditioners
<br />I
<br />lf1t ty'l
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