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ELECTRICAL.INSPECTOR RECORD
<br />OWNER BUII,DER DEI,CARATION
<br />I hcr.bt alrtm !.ddr pctulry or ri..jury rh l d dcmfl fu. rhc C.nr&i.n Ltcnsc tjw l.r rhc forlowins rcastr (5(.?011.5
<br />Itusincss and Ptulesion codc): Any ciry or coudy shich rcqntcl . pcnnil t. .otrsrruct. rllcr. im[tro{. dcmlhn or rcnan rny
<br />rrrucrulc. t'riorro its issu(mc. ako requncs thc a,rplictro' lor su.h l.irnit ro filc ! siEncd srurcnEnr rhlr hcor (hc n liccn\cd N^ua
<br />h rhc pruvlsiont olrhc Cd ircror's Li..nscd ttrw (Chat'rcr L ConmcNin8 {ilh Scctio. T[XX) o, Divnnnr I oflhc Busnrs ond
<br />l,rcic$ionsCodc)orrhar hcorshc hcxcnDr rhcrcfon!*l rhclisis for Ih. rllcscd cxcmpr ion. An, vn,hrn'norSccrionT0ll5 hy any
<br />+llicant for a pcrmil subrcrs lhc lrllicanrro!civilpcnaltyoanormrerhlnlivchuidreddollm(S5lD).
<br />I. * owmr of rh. t ,Fny, or nrt .nq,lotr.s wirh was$ ,\ rh.rr $k .ompcNrliotr. Nill no thc Nort md ltE srEtE n nor
<br />inlcrd.d or ofltr cd lor slc (SLr.7or4. ausircss nnd Prcf.si.n\ ('odc Thc Gntrackn s l-iccnr ljw docs nor arrply b !n owi$ ol
<br />rhe pmlf,ny wtx, htilds or iqrers rlrc@( ud who nmr snch srt hims.lf or hcBcla u rhn,u-!h his .r h.i orn cnployccs.
<br />provilcd thursu.h iDpr,vcnrtrsrN ml iNcndcd or off.Ed for\ L lt la)w.vd. rh! tn,ildinB .! inprov.nEnl is soll *irhinonc )qr
<br />otonrykrion. rhc Owmr Buildcr will halc rhc hurdcn oftmvin8 rhl hc or rhc dil mr $!ild or irymvc rhc pmpcny fn rhr pu{nr of
<br />-1.
<br />asowncroirhcnm|x y. rnrcxclusivclyconlridiry sirh liccn*dconlracroFlncon{o.r rhr rojccr (scc 7(A4. Bu$ncss
<br />Jxl &otr.siD Gdc: Thc Conkacttr s t-i.cn\c l-a* docs nol lpply b an o$.cr oflln,ptdy wh,, huilds.r inprovcs rhcrcon.
<br />nnd who cotrr..tsn such pmjccls qith ! (.onrfrci0(s) licctrrd Nrsurtrl h the conrrlcrols l,icctrk lrr )
<br />-l
<br />amcxc rpl unders€lion-. B
<br />o"., *€L 4'
<br />OECI.AEAIION
<br />I tcrchy lftt undcr pcnalryoaDcljulyom orrhe lollo*ine d€lararions:
<br />trtff C'r)d., ntrrhcpcrlarnrir.ofrhc trork r{tr*hi.h rhr t^-nnir a i$u.d
<br />rhc wo* t, $hich rhisFrnri! is i\sucrl Mysor[crr ompcnsJr ion in\urrmc crricr x]B,lict nunh-r m:
<br />l.cdirrrhrrinrhcpclrornurccorrh.*orkinshthrhtpcrn,iri\nsucd.Ishallioi.'!byrtrypcFoni.trnymonrcr
<br />b slo h.conr subF;l io thc porkcis conrrcnrdiotr hws ofcuhlornin.0nd .3N lhll ilI shouli bccoD subjNr b rhc
<br />wo,kcis'compcns.riontrovhio.sofSatn,n3T(DnirhctjtxtrCodc.lstull,ionhNilhcomnllsirhrh.srrovisions
<br />WAI{NlNcr Frilurc lo $curc aorkcs .onlEnsrrn{ covcrilc is trfh$lul. rnd shrll s'6Jc.r rn cnr|loycr b crnninf,l pcitrhi.s rnd
<br />fincs up ro onc hundrcJ thoxsand dollns (3luJ,ffx)), ir iddirion k,olcorDcn\rri(tr,. danBEC\ rs pn'vid.!l l(tr rhc
<br />ion 3076 of rhc tihn Codc. irrcrcsl md rrrormy
<br />u^",fidL/8'
<br />DECIJAAIIIIN
<br />I hcrcl'y lmrm undcr pcnllry of perjlry rhar I !o li.cned undcr povnion ofChaprc.9 (c.nmncing wnh sdbn ruxrr olDivnion.l
<br />of lhc Blsincss and Pmfcssions Conc. ond nry liccnrc h in full foE and cfial
<br />IAIiIBIJqIDNIBDINC.AAIiNCT
<br />I hcrcl,y al1]In und.r l{rulryofpcrjury rhd rhcrc i\ a onntudirn ktolid! {cn.t r.r rhc pdlornui.c olthc mrk l'or which Ihn pcmril k
<br />ksucd (Scc.3097,Civ. C ).
<br />Af,TLIIINLIJIjQANATOT
<br />llrEbyilitDunncr p.tulr} ol p.rtur) onc or rhc lbll.r irg nc.Lrrrli.nr
<br />l)c n,lirr Icnn \A\br{otNoriil.rri( l;cddrlIt.!ulnri({\(Iirlc.l).l,{n6r
<br />Rcqui'c hrr$of Norili.dtrir
<br />l.cnilyrI rhc lc(l.rrlrcEuldir)nc rgrr]int r\I{'{.\rcnr*Jlrr. r,tr upli.$1. n, !hn |m,t .r
<br />1..'riry rhrr lhr\c r. rha ipnli.rrn rRl rrrcrhrr rtu rhrc itr,nnnri(nr x.onc(r lnc(a r)(n\)lyuirhrllC(t rtrd C,tr(ny
<br />o',liDrn.c\ r d Srrru IiqsrL iiS kr huikli'rE r,rdhcrbrrorln,'7xEfrcs. arivcsorrhisCny.ndCoutrrylocflrcrnlmnrlE
<br />rh.ve nrnrion.d nrcncn! f
<br />Applicnnr nr AEenl Sian!rrrc
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Solfit Rouoh
<br />Ceilings (T-Bar Rough)
<br />[/]eter Release
<br />Rough
<br />Service Meter
<br />FINAL 9.2342 '/)elx bfrg
<br />Notes, Remarks, Etc.
<br />fuJ ,rrr"F*r-q',
<br />Site-Work
<br />Transformers
<br />trnd.r'. AJl](s.:
<br />r -]--
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