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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE tD/stG.COMMENTS OWNER BUILDEN DELCARATION
<br />I hercby aihrm undcr p€Mlry r'f pcrjury rhlr I !d cxcrrpr iiom rhc Ornrrado6 l.icensc L2w f.r rhc rollowinS rcarn (Scc?Oll5
<br />Busincss and Protcssion Codc) Any Ciry or C.! y whi.h 4qunc\ a Fmir ro con(n.r, rl'd. i'ntmrc, dcmlisn or rclon any
<br />{tucrorc, prior b ih nsuonc.. ,ls rcgukl
<br />'hc ryplicur for {ch pcrmit ro lil. 3 sigRd sr cmnl lhll hc or she h li.enEd puNanl
<br />ro rhc pmvisions ol lh. Cont@d.is Liccn$d Liw (Cnaprcr 9. ComncncinC *irh skrbn 7o0o .r oivision I of lhc Bulitrcss and
<br />Prufc$ions Cc\dr) o. rhd h. or shc n cx.n{'r lterclron a.d rrE b{sh lor lhc alk8ed cxcmption AnyriohrionDrse'hn?0r1.5 by,ny
<br />apllicanr ior s Fmir rutrccrs !h. 'tplictr.r t, a .i!il pcnalrt of nor mr rhan nv. hundrcd dolldr (S5m).
<br />4"*"* "t r* 1,"pny. or my cmrloyes wirn wascs !s rh.r hk compcNatFn. qlrl do rhc *ork ard rh. {Mm is mr
<br />inrcd.n or oficE'd for sh (Se ?Or4, B!\iN* lnd Pmfd\ions Code Thc Conr6cttr r Licc.r. b* {io.s nor apply lo !n o*rcr ol
<br />rh. pmJ.ry who b{ilds or inpmws
<br />'h.]Nn.
<br />torl wrb dc such wlk hi'rsclf or he^clf or lhreush his or hcr o*n cnrloy..s.
<br />Drovidcd rhor$.h impmEmnrs m en inlcndoroocrcd fo.sh ll h.scvr. rhc i,iHinr or ihtohmd hsold withinonc Fo
<br />ofcoq,lc'bn.th. owncr auil(ln wil n0!. rtE bodcn of,,mvinB lhor hc or snc dii ml teih or iqnot 6c pmFny ror il! purlbr or
<br />-1.asowncrorrl[prcpcny.amcxclurilclycorraclinswnhliccn*dconrracn$r.consrdcirhcpn,j*r(scc704.1,Busirasand Pblia\k. Codc: Th.Con[r.rofs Li.cn\c Luw docs nor{tlyr. atrowmrofrrcp. ywhohuilds.rinrFovcsrhcrcon,
<br />and who .oolra.k for uch projccr\wirhoCont0chns) liccnrcd pursu,nr tiihdContr.rtrh l-i.cnsr ljw).
<br />I lmcremDt Lndcr Sccrion .B &P.C!a
<br />DEIIAMII!}N
<br />I hcrcby oflnnundcr p.trdlyol lcrjury om olrhc lollorins dahrutionr
<br />_l h0vc ad *ill minhin a C.difrdc or C.nrrr b sclf lnsurc aor suk .r .o.F(nsarb.. is pmridcd lor hy Scclbn .17(xr or rhc
<br />libo. Codc, Lr rhc pslonurcc .l lhc *ork ritr *hici rh. Pcmir h h\ucd
<br />I lrvc rnd vlll minraii wo.kcrJ .omFns ion insuramc, !s rcqun d byScrliotr 3700ol'lhc l-lbor C c. i(rrh. ldfornumc or
<br />rhc workforvhkh rhisFrnrn is issu.n. Myworkd{ conD.nsriion insurrmc cdris ond Flicy nun$cr m:
<br />/j/cnrly lhd rn rhc nnrorNncc,,trhc *orl xtr trh'ch rhn Frnril i\ ii\!cd.l \hrll ior cmpbr.ny p.non rn rny monncr
<br />v, ^ b b.com subjNr ro rhc wo*.rs .onu.ns0rio laws or C,lit,ni,. lnd a!rc lhat ifI should bccom subicr 16rh
<br />sork.B cdry,cislrionnmlisi,n( ofS*lnrn l7mof rhc tjtrtr Codc.I shall. fonh*irh comply wirh rhos nmvisi(,ns
<br />WARNING: Frilur. k, \c.urc w{rkcrs .onDcDsilnnr covcr,lc is u.laslul. and shall \uhjccl !n cnrnk'rcr h 6i'niDil pcmhics.nd
<br />civil ,in.{ up b onc hrn,lrcd ih.usrnd d.1lr6 (Sloo.fi{)), r dddiriotr to rhc con olcomFnsaridr. da'nr!.s trs f'ovdcd lor rhc
<br />Sc.rtnr 1076ofrhc LltxtrCl)',c. irrcrc(od dkrrcy s lccs
<br />Llllixuiu_rcrlx cra-B
<br />DIillzLBILlQN
<br />I hcrh, alfinn und., rcoahr .f p.rjury rh r l 6m liensd undcr FDlision ol Ch.FIcr 9 (commmins *irh Ssrion 7(xD) or Dilkion .l
<br />of lnc Busims lnd Pntsnrns Codc. and nry licc"sc is in tull iorce ald €afecr.
<br />Con(roclor
<br />C(TNSTRUCT'IoN LFNDING AGIiNCI
<br />I hcrcby.lltrnr lndcr lEnalryol Frjury drlr rhqc isr conslmlhn lcndins aBcky for rhd p.rrornBr. olth. work rhr which lhis pcmi n
<br />issucd (Sc.. :1097. Civ. C.)
<br />AIILICANLD!:IIABAIIAN
<br />I irrb!,Rion hdcr p€nrhyofpcrjuryonc df(hc loUown'8 dccldariotrs:
<br />Ixmolirion Pcrmirs'Ash.sros Notincorion FcdcolRcsllorions (Tirle 40, Pan6)
<br />-Rcquircd
<br />txllcr or NotifE{tion
<br />l..nifyihar ihd f.Jcirl rcguldriotrs E86dnr8 Nbrnos rcnbvaluc not lprlicablelo lhh pord
<br />&(,.nn, ,n , , *," nuo ,nr apprtrrn,n !.d dsrc rhar he lhor in i\ c.tu.r.I nE6 ro.onrly wirh rllCiryrnd Couniy
<br />r.rr.enuivcs ofrhis Cir, !trd Counrr ro cnrer up.n rhcorlinarccsand Stalc trws rchtinalo hu iklin8 condnrdi{nr rd hc
<br />f Guh;z-arz-
<br />J -r7- Zoi
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Bondinq / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Sollit Rouqh
<br />Ceilings (T-Bar Rough)
<br />Meter Release
<br />Rough
<br />Service lVleter ')I
<br />FINAL ){/zr/fi -..Blrj I
<br />Notes, Remarks, Etc.
<br />Under Slab / Floor
<br />,,*,- 8.'tj - ?otS,rprrri.rnr:)a
<br />I
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