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ELECTRICAL.INSPECTOR RECORD
<br />D tD/stG.APPROVALS COMMENTS OWNER Dt]II-DER DELCARATTON
<br />I hcrcby alfinn nnncr pcnrlry ol p.rjury rhar I !n cxcmpt fm'n rhc Co racnn l-i(nr ltr* lor rhc rouosing r.asn is.c70ll.5
<br />Brsincs\ ! l Prolt$ion C(xlc): Any Ciry or Counr, whtch rcquirF a Fnni! h sn{ru.i. allci innmvc, dcmlhh or rcErn any
<br />slflcntrc. t]rnrr. ira h\unncc. lho r.qutcs rh. {rplicrnr fq \ chIlcnhirro filc r \igtrcd n cfrl rhar hc.r sh. is liccnscd puruanr Ih lhc pNvGions olthc Contmcrols Li.cnsd bw lch prr 9, Com'ndn.ing snh Sc.rn,n 7000 oiDivirtr.l ol lhc Businct rnd
<br />PNrc*ion\ Codc ) or rhlr hcorshc iscxcnrpr rhcEfrofla rhc bosn f rhc allcscd crenun,. AtryliolarionofScdi,n7O1l5hynny
<br />appli.rtrl f.r ! Flnrn \ubJ..hrk aplli.unr lo dcivilpcnulryolnornnrcrhln l_rvc h!ndrc.ldollurs l$500).
<br />-1.
<br />as otnn of thc tmFny. or my cnDlorr.s wilh w,g.r thc ir n, L (r, mr.nral ion. uilldd rh. wrk d,n lh. {mum i\ tu(
<br />intcnd.t or ollercd lor ek (Se.7lr4. ausincs Pmrcssn,nr CdL Thc cdnkNor's Liccn{ Lrw d&s nor lprly ro an owfti dr
<br />thc Dmpcny wh. boiktx or imtms rtrdrn, a wln dms sEh slt hinsclf or hcrclf or thmu8h hn or her .sn cnfloyccs-
<br />,rtuvidcd thtrr skh imptu[mnc m fln inkrdcd o, ofier.d for elc. lt hoEur. rlr huruin8 or in!. ,EnE.t h $ld sirhin oqw
<br />or cdnDlcrk,n, rhc O*nc. lluildcr *ill hlt rhc budcn ol EovnE lh.l hc or shc did nol build or imtmrc ft lmFny for tl.c pu4n€ oa
<br />-l-
<br />aso*ncrof Ihc pmrcny. ! cxclusivcly cotrlr.cr ing wirh li.cnsdl .onr..r.u ro mnsnd r hc pmF..' (Scc 7(}'l,|. Bunncs
<br />,nd I'i,rc$kJi Codc:'l-h. Conrtuctr's Liccns€ l,aw docs nor lpply Io un owrcr ol'propcrry sno builds or improvci rhcrcon.
<br />lnd wno.utmclrforsu.hpmic{cwirhacoNa.kd\)li.cn\cdru*u.rbrhoconra.kysLi..nsbw).
<br />-l
<br />lnrcxcmpl urdcr Sdiotr-, B. & P.C. forthis rcNJn
<br />Dele: O*...
<br />wonxris' r:rrupir.rslrxlJ
<br />![cr.a.8alla!
<br />I hcrct y aaltn undcr Foally of Frjuiy om ol thc folhwinS dcclrarnrns:
<br />-l
<br />havc und will nmintlin n CcnifEarc ol Con* nr sclr.lnsu,. ror workc6' $nrpc.salion, rs povidcdlorbyScclionlT00ofrhc
<br />Lnhor Corlc. for thc pcrform^..c ol lhc vork for whi.h rh. Fnnir ir is\u.d
<br />Xll;l'll willflrainloinworkcE.onucnsolioninsurrmc,,snqundbySccrn,nl?moflheLnb.rCodc.forrhcpcrloflnrnccol
<br />} wortec' comrns i.n imurfiEc c0ri$ nM Flicy nunrhcr irc:
<br />e3
<br />?t.a-O a
<br />IccniryrhrlinrhcpcrlornNreoilh.workritr$hichrhr!Iicnnislrsucd,I\hlltror.qloyrtrylrrotr rnyn$nNr
<br />$ r\ to k\o r suhl.rr r) rhc w.*.^'onl|].isrr im hw\ ol Crlllan,ir. rnd 4ft rhd ir I \k,uhi h.com \uhicr t, rh.
<br />workcn'.otrrt trsrri( pmirion\.iSdi,:l7mofrhcIf,htrGnlc.I\htrlllnnh$irh.ordywirhrho{!tuvni(,s
<br />.ivil linc\ up t, onc hrndrd rhousnd:::wT{
<br />conpcn\ari{,n covcrusc is nnl wtul. 3nd \hl
<br />dollan (Sl(X)nnr in xddirion ro rhc cod
<br />Lll sul,lccr an enllnotcr t, dni.al linrliis xnd
<br />ofc{mnenerion. dntusc\ rr !6vidcd lo, lhc
<br />I h.sby arfird undcr lcnahyol p..jury rh,r I a'n lic.n$d uulcr pmvirt'n ot Chaprcr 9 (dnnnEnclng eirh Sc.rt,n 7000).1 Divi\nnr:l
<br />of rhc 0uircs and PrcIc$iorr Code, un my liccnsc is in full forc ond .lI&1.
<br />C-ZC)
<br />t s
<br />CONIIA!]CIIONI.ENDINCIIiENCI
<br />I hcrchy afirm undcr lcnally ot pcrjury lhol lhcr h a .onsldclion knding o8lncy for lhc lcrformrncc of lhc qort ,br which lhh ,cflnil Ls
<br />hsucn (Se. 3097. Cir. C.).
<br />AITIJqANLDEIIIAAIPN
<br />I h.r6, anim undcr pcnolty ofpcryryonc olrh.followi.g d.clrarions:
<br />Dcnbliliotr PcnniB-Asbcsros Noiifi.arion Fcdft.l Rcgtlartr.i (Tirle 40, Pan6)
<br />R6qrtun bircr of Norilicltion
<br />I ccnnirh rhc,adcralr.!nl.lion\ togrdnr! n\b.{o$ctrxxrl rrc mrrppliclhlc b rhi\ pfl,j.cr
<br />*l ccnify lhar I harc rcod this application flxl srarc th,t rh. fi,ve inromri,n is.oft.cl.I agN lo.r
<br />ordimnccs rtrd Shrc bws rclatinE to building.onsrru.!io6. and hcr.bydurhorte r.,)!.rnlarivcs otrhis
<br />.'hr. n.nri.trftt bn,..nvrur h..ri.in. m,r\
<br />nrr,**, -n*-,.r*.*r- Z
<br />P.n,,,renamc,pri,: Xg7 $t/2rt<
<br />nrrlr" wirh rll cirl.trd counry':';);'?;'r-
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Life Satety /Low Voltaqe
<br />Fi re Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Eqlding / Grounding / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceili4gs (Hard & Soff it Rouoh
<br />Cei lings (T-Bar Rough)
<br />Meter Release
<br />Rough
<br />Service Meter r
<br />FINAL a t4€ -/o/41 ('U
<br />Notes Remarks Etc.
<br />Siqns (monument)
<br />Ltn.lcr'' AdJrc*
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