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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE IDiSIG.COMMENTS <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Lite Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Bualdinq <br />Under Slab / Floor <br />Bondinq / Groundino / UFER <br />Translormers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinos (Hard & Soflit Rouqh <br />Ceilings (T-Bar Rouoh) <br />Meter Release <br />Rough <br />Service Meler I <br />FINAL I rlilr( 1 2vYi6/lY tn -r/ <br />Notes, Remarks, Etc. <br />OWNER AUILDER DEI-CARAr'lON <br />I hcrchy,riir und$ p.Mlly of pcrjury rnd I m €r.'npt fron rh. cro.tado6' l-icens uw rrtr rhc rollowinS rcoen rsccrrl1l l <br />Busincss ond Proicssion Cixlc) A.y cny or Coutrly which rc4uire\ ! Frnrir h constDcl, .lts. im[oec dcnoliqh or rcl|n anv <br />(rucrurc. prior ro ns iiauanc., al$ mquncs thc spDlksnl lor such pclnri' r. lilc o siCrcd n.lcmtrr thol h. ot shc h li.cned pusua <br />r, rhc pi.visions orl}E Conkrcrols Liccned tls (Chrrr$ 9, Comnmci!8 sirh Scclion 70m dr oivision 3 oflhe Busincs\ a.d <br />PofcsionrCodclorrharhcorshehcr.mprrh.,crromsndthcbashlorrhcallcscncrtmprioi.Anyviol.lionofSccli.nT0ll5by.ny <br />arplicad lnrdp.mir sobje( lhc amlic0nl lo acililp.nlllrolnor dorcrhan rivc hu rcd dollar (550]()) <br />-1. <br />!s owrEr oi lie pmpcfly. (r fry cmtlo)trs Nnh w08cs as thcit slc .onucisdnrn. {ill do rh. w(k ud rhc slfth is ml <br />inrefthd or o,IcEd fff slc (s(.7(,,r. Busiflc$ md Profc$n'ns Codc, Thc (-dnkacktr\ Liccns Lsw docs nor .p!,ly r. m owmr of <br />rh. rtupcdy who builds or i,rw(,vs th.rdn. Md who rltf,s ruch w* himscll o, hcr*lfor rhmu8h hn or ncr oNn cnlPlr'r.cs. <br />pruvidcd rhri sr.h irnl,ov.nEtrls .rc mr i cxlcd o! olTcrd foi {le. Il houcEr ilx hikling or iryrtuEmnl k bld *irhh onc )t tr <br />ofcoq)lcriofl, r Ouncr AriHc. sill hnw rh. budcn .f rruvins Ihal he (tr shc dir nor huih or inpm\t thc lmFny for lhc lurlns oi <br />L asowncr olrtu prcFdy. {r.crlusiv.lyconkrctin! *irh lienscd cotrtrctor ro.oNrucr rhe poi..r (S{.7044 8^i..* <br />d tlnlt$ir c{dc: 'I h. Cotrta.ror's Liccnsc Llw d.cl nor opply k, rn.wtrci orPruFny wno builds or nnprcvcs lhcrcon. <br />Md who.o acts lor sucn rrcjecrs wirh r cunka.bi0 liccnsL{ pur lnr ro rh. contu.ror's t-icctrrc L.w). <br />I db cxcnro undcr Sel a & PC. f(r rhh rcason <br />u!18.6[8sra]fi;NsaraN <br />DECI.A.EAION <br />I herehynlnrfl rndcr r.n,lrt.f pcrjuryonc olrhc lolk,*ins Jcchrarn)nl <br />-l <br />have unl will &imdn d C.dificatc of Con*nl to Scll lnsu,c fo. w.rkc* co'n|xns.lion. os pNlid.d r.rbts.clion]?OOoirhc <br />Ijb.r Codc. for lhc pcrr'orroncc orth. work ior whi.h ln pcrm i! nsucn <br />-lhrrcandwillman <br />trh work.rs compcn$ri.n iDsurrncc. !\ rcqtircd bt Sccrion l7O0 ofrhc Lnhor Codc. for thc pcnorroncc of <br />rh. wort r{tr whichrhi\t$nril is nsucd MyNorkcis conf.nsrrn,n nNrr.mccndcr aDd Poli., nu'nhnac <br />-lccnilylhrl <br />inrhc pcrfoflenccofrhc w..k lor whicl lhk tcrnril is is .d.l shdllnol cmploy!tryPc^oo ina.y nrtrrcr <br />$ n\ t, bc$ft subrd ro rhc workc6 onDcnsarn,n h{s olCtliforni.. $d l8rcc rhat ial rhould lrtom subrd to lnc <br />work6.dmpcnsdionpnrisionrotScdn,n]T0oorihcbtnc'odc.lsh.ll.lonhwnhcomPly*nhrhocprovishns <br />WARNNC: l:lilurc r{, {curc workc .unoctrsilion .ovcrr8c is unL*ru!. iM nrill suhjccr rn .nrPbtq ro dniMl lEmhi\ tnd <br />civil finc\ up lo o& htrndrdd rhous,M doll.n (rhr cos ol'compcnsalion. d,m,!.r ,s [ovidcd tor rhc <br />w'ww" <br />ll!(trr$dnq! <br />I hcrcby rllt rundcr pcnahyorpcrJury uMcr provisio. or Ch{ $ 9 ( connrEncnr8 q ilh Sd ion 7m0) of Di! nion :l <br />of rh. BusircssrM Pn'ic$ioN O)dc- ail fry li.dn{ il in full inrccarn,clt cl <br />b <br />g <br />I hcreby rlnrundcr p.nalry ol |rrjury rhnr <br />i\su.d rsc. 109?. Civ C ) <br />rucrion lcndi'r8 rgcncy tu Ihc P.raomtc ofrhc wtrk lor $hich rht Fnnir ir <br />APILICANLDECIABAIION <br />I hcr+/ydnimundc. pcn ly of rerjury onc orrhc nrhwiiS d(ldarions: <br />Dcmlirnnr Pcrnik Asb.sror Nolifi. ion rtdcril Rc8llnr ioor (Tnk 40. P.n6) <br />RcquiNl IlIl$ of Notilksion <br />l.cfifyrl rhcfcdcrrlrcsulrrions nlrtirs ashc(os r cN)r{l n.c ror rfPli.rhl. k,rhi\ lmiccl <br />n.or..r IrqraIo..nrply*irhrllC'ryitrdC.nnl) <br />rprc\cnrdilcc nfrnn Cny and Counryti c.rr ufnr rlE <br />CC <br />,.,., qb:B <br />Poli.) Ndi,h.r E\tirc\ <br />- <br />9oe <br />Ixndf . A.ld'c.\ <br />- <br />: <br />tl <br />I <br />fT