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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrchy ltiirnr undcr p.nllry of p.rjury lh.l I {n.r.'nFr rmn rh. Cn racloa' Licnsc tiw for lhc followiry rc0sn (Scc.?01r.5 <br />Bosnrcs\ ind Proltsion Codc): Any Cil, o! Counry rhich Equncs 0 Fmn to conxlrucl. llter. improrc. &nolish o, ftpat any, <br />{d.ruc, ri, t, ir* irsr,rcc. rlso rquircs rhc +plta.r ror \uch rEmir lo filc ! siEn.d d.ftnt rhd tr oi shc is liccned pusuo <br />kr thc pmvnions of dr c'onlrocrois Liccn*d bw (Chapl.r 9, ComnrncinS wirh Scctnrn ?OD ot Divhnrn :l oflhc Busnr$ and <br />ProlisionsCodc)orlhallrorshchexcmpllhcrcfnrann$ebasislbrlhcallcecdcxcnurlion.AnyviohttunotStri,nT0.ll5hyany <br />,mlicanllorapcrmilsubjcclsrhcapnlicurlo0civilrcnoltyofnolNrcth!nfivchundrcddollars($50(,) <br />-1, <br />as owrcr o{ rhc pmtcny. or my cmflores rnh wnScr * rhcn elc .lmpcnsrrion. will do lhc w.rt rdltEshrlurc n nol <br />ii cndcd or oficrcd for elc (Se.7Or4. Busircsr and Po,c$ions Codc: Ihe Conrractois l-icns U* doc\ nor ryp!, k, an .* nn or <br />thc nmlEny vho boilds or irpmB rhcN)n. lrxl wh. d&s \kh Mi hnn\cltor hc6.lfor thou8h his or lEr osncmplorecs. <br />Frdvidcd rtur \nch i'npmrnrnG at mr i cod.d or orlcrc'l ror eh. lt Iarwctu. rhc huilllin8 or irllprnEnE is mrd wirhin nm Jrr <br />ol cohptclion. lhc Owncr Buildc. will h.rc rhc h{dcn ol prcving rhd h. or shc dil en hoil1 or im0olc rhc J'mpcny ror hc rurFE.I <br />-l- <br />asowncrofrhcproleny. !fl.xclusivclyco m.rin8 wii h liccnscd conrrudoF ro con{rucr rhc rmjc.r (S( 7ol4. Br\dc\s <br />i, Pof6si,nCode: The Co.trc!{r\ Lic.nsc Ltrs docs nor upply ro en ound.fptup.ny sho builds or irnptuvus rhcrcon. <br />and eho cotrrroch lbr iuch pmjcds wirh r Cotrrftto(9 liccnscd pursu.nr rorhcci)nrmcrolsLiccnsc Law) <br />-l <br />amcxcnu,t under Sdn,n-. B &PC lhrlhirrasotr <br />]loa(fas:louxfrla-ultN <br />Dlr!ir&r1laN <br />I h.r.6y aifinundc! pcnolryoipcriuryorc ofrne i.lLBina dccl.nrio.s <br />-l <br />havcard will minr,in a Ccnificarc of Con$nl h S.lr.lnsuEr.r workm omDctrstiotr. ar u'vidcd for by Ssrion:170(, olrhc <br />tihor Codc, for thc FrfornM.c olthc wo* lor which rhc p.,.nl is is\n.d. <br />_l har and will minrain w.rkc6 conDensarnnr insuaNc. 0{ rcquic{ by Sccr ion lr({) of lhe tnhor Codc, ntr rh. p.dnne'u ol <br />rhc $or( forwhichrhn pfmir is issed My*orkcc conrpcnsrri.tr insuEmcclrier lrxl polty nu.tEr sc: <br />I ccnifyrhar nr rtu ncrlormne ot rhc aort lo whichlnh pcflnil i\ hsucd.l \hall noi cn'rn,ylnrF-^on in any'nntrn.r <br />h Nroh.cum suhr..rr, rh.wo*. conlE.\rrio l,w\ of Cllifonir. md r8rud rhd ifI sh.uld trronf, subjd rottE <br />*orkcn .onp.n\,ion pmeni,nsofScction 3?(Xlofrh. bt rCodc.l \hall. fonhuirhcotrlt'lt withrhor pmvtioni.. <br />WAiNIN(; Friluc ro sun s( .ri conrrcnurion cov.ragc i\ onhwtul. ind $rl! \ubjccr rn. lFk,rtr r. ai'nnul NMtics rtrd <br />c l tltrcs ut td on. hundrc rhous..d dxlles ($lm.m,o), ii !o rhc.o{r or.onD.nsrion, daro8cs as providcd lor thc <br />SNri.n:lo76.f rh.lih'ra..lc i' ..c( tr.J , lrmv' <br />",,", ef ts f lc ^,,,*., <br />I tur.hy x,lir u .r F-mlry,'l ll.rjrt rhrr I rm lic.tr{Lt olChq,rcr9l$nnNn.i',gtrirhSrdin,?UxDol D^itil :l <br />of rhc Businc$ md Pmfcsions Codc. md mylicctrsc is infu0 lnrcc!dcllccr <br />czc:2j <br />G tc /9 <br />l\!,.rlis.( lr)i)r ( i\ ( l <br />APPLTCANT DFCI {RATII)N <br />I My afiirm undcr pcnahyofpcrjuryonc orrhc followinS dcclarurions: <br />Dcmlnion Pcrnt$Asb.(os Norifi.alion F.d$al R.guhrtuns (TirL40. Pd6) <br />-Rqtuncd <br />htrcrof Nolirr hn <br />I rcniryrharlt tnc.rlr.guIrir)n\ rgxrlnr! rstr{os8trr)vrl)rc n.rrflrli. I r) rhn F)jocr <br />I ccn,ryih lharc mtrdrhn qrplicrrn,i,rn $.om.r Ir8rrt,o \n\*irhrll(irvr ((iunry <br />ordnEk.( a d Srarctlwsrlalin8 ro <br />iti,lc tftntioned proFn, t6r inspcct <br />Applienr or Ageol Sls@t!rc: _ <br />P€mllft nrm. (prlnl,: <br />* ^". " "'::'';f)';f0"""" <br />Site-Work <br />Underground <br />Light Standards <br />Spas, Pool , Fountains <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bonding / Groundinq / UFER <br />Translormers <br />Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Rool Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soffit Rouoh <br />Ceilings (T-Bar Rouoh) <br />Rough <br />Service Meter ,.-1 <br />FINAL 6 .zr'{6 /,,{c z ) <br />Notes, Remarks, Etc <br />Pole Bases <br />Sions (monument) <br />lVleter Release <br />L.ndrt Ad&rs: <br />- <br />--T_------ <br />= <br />I <br />I <br />I <br />=