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ELECTRICAL-INSPECTOR RECOBD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUII,DER DELCAiATION
<br />I hcrb, aflirm und.r l.nrlr, of lEriury rhur I 0m cxcmpt fmn rhc Conlncro6 t-icdn* b* ror rh. rollowin8 Eisn lS( 7{r:1 1 .5
<br />Bu\inc$ lnd P.otcssion Cnle): A.y Cily or Counry whth rcqonB a trmit lo mnslru . ahcr. ioprolc, d(mlhh I rcNir Mt
<br />jrru.rur. trior ro irs i\ru0mc. dso nquircs lhc 0ptli.ml lor such pcirnit lo filca {istrcd rarcftnr rhol h.or shc h liccnscd lursanr
<br />ro rhc F,visions .f llt Conrra.roas l-iccnsd t:w (chapt.r 9, Co'nmcminS wirh Sccrion 7(ID of Division I orrhc Bustrss,nd
<br />Por.sions C.d.) or rhnr h.orshc is.xcmFl lhcrciro'nand rhchask forlhcallcscdcic'nprion Any vi.l.liotrofsNtionT0.ll J hylny
<br />afDlic,nr iora Fflnil sublck rhc ipplic.nr ro acivilDcnaltyofnor nDre rhan fiv. hundrcd dolld6 ($500)
<br />l. N own.r of lhc l)oNny, an cxclusircly conlrrl ir-a eith liccnsd conltut,F b .onsru.r rhc tii)jel (Scc 7044- Btr$ncs
<br />! PnnilsinCoie-lhcConrs.ttr'rLi.cnset-rwdocsnorartlytoutrosncrolltopcnyNhobuikl\ornnrrcv.srhcrcon.
<br />n eho.onn,crlorsuchpmrthwirhoco,rracio(nlicctr*dpusudbrh.c.nt,cror'sL,cctrscLaw).
<br />I aDcrcmnr undcr SccrFn .B &PC torrhNcJ\,n
<br />lVt )RXFRS', ( l()lu PFNSATI( rN
<br />DfcttS^urlN
<br />I hcrcby rffilnhdcr Fnrlrt of p.Uury o.c ofrhc lbllosillg dc.hr.riotrs
<br />-l
<br />h0vc atrd willmrintrin a Ccnificlrc.tConscnrto S.lf lnsu,c rd workc6' dompcnsalion- as providcd rorbySecrionl?uroflhc
<br />bhor codc. ror
<br />'hc
<br />Ifriormncc ofrhc so* rbr whict lhe pcmil i! issled
<br />-l
<br />h3rcann qillmoinrain *orkcri co lrnsarn)n insfirn.c, !s rcquncd hyScclion:r?(xrofrlt lrhorGdc. fot rhc Pcrfonmmc ot
<br />,,'.(4aletr,.cl tc6 conDcnsarbn iFuranccodcr d [x,li.y nunb.r m
<br />I cdnlryrlur in rrr ncrrormn.colthc wor* nn *hichlhis ncflnil t h\u.d,I \htll nor ..rtloy any llcnon in lntmntur
<br />s nsh hcurc ubjccr rorhc *orkc^ coilp.trsrrioi h*sorcnlironu. lnd l8rcc rh ill should bcc.tu subj&1rotrr
<br />uorkcs conrpcnsdionl[)vtionsofSc.ri(,n.17fi)olrhc Llrr Clrlc,I sh.ll. fonh*ith comoly *irh rho{ F,vnn s.
<br />IVARNIN(; Irrllurc t) sccurc *orkcr\ co pcn\ i,rr co'srgc i\ utrlrtrul, hd shrll{rbicr tn cnrflo$r b .ri'ni rl lcnrhrc\ dd
<br />.ivil litrcs un ru otrc hlndrcd thouetrd do
<br />;:::j#,Jidl:
<br />rion. dxnugcs r\ pi nlcd lnr rhc
<br />I lErchyrilirru cr |r.nrlryolt)c'jnr_ rlrr I itrr un(lcr ,rni n ol (hup(cr 9 (coDnncnci',I snh Sc.ri(r] TUXr) ol l)ni\i(n, .1
<br />ol rhc Eusincs ind Pdts\ion\Codc. ml my liccnsc i\ in iillnra md cftc.r
<br />b, c4t,sla4if ..",."",..
<br />I hcrchy afiirm trnd.r Fialry.fpcr,llr, rh0t ihclc i\ a
<br />issucd (Src.309'7. Civ C ).
<br />iotr lcndirgaacnc, for rhc F-rlorm'n.c .l rlE $ork lhr *hich rhis p.rn,ir n
<br />AIII.LCANLIECIABAIION
<br />I h€l*Jy afmundcr Fnalry orF.jury orc of lhc lollowin8 declorarions:
<br />D.lmlirion Permic-Asbcstos Noril_'cario. F.d&.| Rclnlat ion (Tirlc 40. Pan6)
<br />-Rcquircd
<br />Lcrrcrof fiorif@rion
<br />-l
<br />.cnif, rhd rh. fcddrl Egularions rcSrdin8 ashcstos rcmvll rc nol a ,ltcabh ro rhk pmit
<br />Q:kcnrlyrh lho(rc rhr lrnlEarionadi,r.rhlr rhc ahv€ inloi@rion h c.r(l. l l8E ro coryrly snh aU Cny a.d coutrr,
<br />odimn.N atrd shrc uws rhriru roslildinS hccby rhri2c rctre*nhrncs or rhn Ciry ,nd Counry ro c.r
<br />bov. rmnrioncd ln)Frly lor iNpcclion
<br />]\rDlirxnl or,\stnl Si!n luru
<br />o5 l,b<&ellqr zfat
<br />",|;;
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bondinq / Groundino / UFER Qlzo/r s ,L/A )
<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 />Ceilinqs (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rough)
<br />lvleler Release
<br />Rough
<br />Service N/eter il?,.1t7.</qe(,)
<br />FINAL lo/11-/rs 1Nc<q-
<br />Notps, rRemarks^Etc.
<br />(,
<br />L,(
<br />-)
<br />Pole Bases
<br />l. ,s owNof (hc ln)p.dy. or my crn{,lo}rcs wnh w!8cs.s rhctr $lc conrB-nslri,,n. willdo rtr sork ond rtE (ndurc n nor
<br />i cd.n or orercd for $k (Sa.?U4. Ilurie$ and Phrcasi.ns Codc: Thc contodols Licen$ Lav dfts mt amly b tn .wftr or
<br />rh.pm|).ny wh. huilds or inDorcs rlrcBn-,rd who dtrs $ch wo& himrcfor h.sclfor lhmuBh hi\ o' her o*n.mploycc..
<br />prolidcd ihar \uch imrmEftnrr m ml int*ln d olT.rcd ror srlc ll houcEr. lic hoiklinS or iirnM'En! ir sld wirhi. one )tu
<br />olo'npbtion. rlf Owncr Buitls wil hrvc ltE burdcn of lovirrS lhul hc or ific dn nor huikl .r inrrov. lhc pmpcny f(n thc n!qn* of
<br />hndcis Nsmc
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