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ELECTRICAL-INSPECTOR RECORD
<br />OWNER BUILDER DELCARATION
<br />I ncrcby il',irm nJcr Fndltyol l,{rjuy lhsl I m Gcnpl fmm lhc Cln rart,6'l-ic..t tlw ror rhc tullowm8 rc!$n (Sc.?0.11.5
<br />Busincs lrl fnfe$on Cixlc): Any Cry or Couhry *n(h tquu.\ d ltmil lo connnr.r. !ll(, imlmvc, &nnisn or Nrar dy
<br />srtucrurc. prior l{r ils issu ., il rqur.\ rh. rpd{,d hr rx.h Fm( lo lllc ! siSncd slalcmnr rhlr tE or shc ir liccnei Nruul
<br />h rhc l)Dv*r,r Dt llr C.ntra.lois Li.cnsd Law (Chapl.r 9. Commercins wirh Sccrtln 7ln0 or Divf$. I oi lhc Blsincs !n'l
<br />Pn{c$i,nsCc,c)orrh.rhcorrhcner.mprrhercnomandrheh$hturrh.rllcs.dcr.m0io..AnyvidllionolScclon?0.ll5by.ny
<br />apth,nr Ibr aFmir lubj.ck rh. aprnc,m ro acivil,).hahyornor mr. rhln lrv. nunJrcd dolkrs (5500).
<br />-1,
<br />is ow.crol th. ln)tEny. ornycm! ryccs w,lh ,as$ rs lh.tr glk qrDn nrario., will do ft. wolk .nl llE srel@ 6 nn
<br />inrcDlol orolicrc! inr s.lc (Ss.7044. Busim$ and Pn)fessionr Col.: The Ont,ctr s Li.ctrs ke &Es nol al'Ply ro an o*hcr oa
<br />rh. pnFn! who huilds or nntbvcs rtuh)4.nd who dds skh s* hhs.llor hcn.llor rhmulh hh or h.r own.ntloyc.s,
<br />lmv*ld rh.l such mr^)rcm.lr m mt i dxlo.l or ofted td srL lf, h.Ncw, lh. hliuhg or inlatmnr i $U w hit orc ]tu
<br />ofonglcri,tr rfi. Own.r BuiliLr wiu hlk rh. burJ.. of ptuvn! rhzr hc or ir dil mr huir.l o rFmvc lh. pn'pcdy for ric llnqn{ o,
<br />L a\owtrc!olrhc ls,pcny, !mcrclu\ivcl, (onrracrrns wnh li.cnsd coDkdcrff t, c.nnrud rhc poicd (Scu. 7044. Rurn.s
<br />Brn$$nCdlc:ThcContra.tx'sl-,c.nscL.edocsnordlplyk)anowncrolpiopcrlywhotiu,lJrorihtn,vcsrh$..n.
<br />.nJ who conrmd { nn \urh tn+ct wirh a conrBcr)(n lEcnkd plruad h rh. cont,.rtrt Llccn{ ljw).
<br />I amcrcmlx utrd{ Sccrn
<br />I h-r.by rl,irmu dcr p.n.Iy.r !rE!!z!r{ro!
<br />I h.r arkl will frrinr0in a CcnilMlc of Cirnsnl to Sclllnsurc ntr rork.r- {omr.nsd ion. rs l'bvilcd tor by S..(ion J7( ofrhc
<br />Ijtu C-odc. ror lh. Frfomtuc ol thc *.rk r'or *ti.n rh. lcmil is i$ued
<br />lhavc rntl wrllmrml.in woltcr'.omp.nlalion in{traorc. ar EquircJ hyS.crx,n l?00o1rhc llbrtr Cqlc. nlrlhc lt.tomBnc. ot
<br />lhc *ork n)rwhichrhr p.mir is i\{kal. M} wo cr'NnDcnsation insur,n& rni.r 6nd tray nnnb.r m:
<br />Cri.._
<br />Policy Ntmb.r:-
<br />_l c.nilyrlrat ir llr pcrlornEncc olthc wo,k ntr sniuh thr r.rnir is nsucd. I null n.r.hploy rny lf,ron n' a., m.nrcr
<br />a, r{ lEom sb]cct to rhc h*si.omFnsalnn l.wr ofCalil,rmir, rnJ rsft rhar fI sbull bc.om rubicur rolhe
<br />work.s.tq,cnsaliorForisionsofS&lion-1700.iih.LahorCodc.Ilhall.n,nhwnhcohl,lywr'hrh)$,Nvisions
<br />WARNING: Fa'lur. h s.nrc workcs' .omFns.l irn covcnEc s unlawtul. and shall slbjcct an enplor.r ro dininal lEn .s Md
<br />I lo om hundrcd lh.nsafr, dollis rfir,o(x,), rn i drotr kr rtu Los. ofconp.n\rion. d.m8.s ls {,{vklcd ktr rh
<br />S.!ri.n 11,?6.Irh.ljhtr(hlc inrcr.(
<br />I MEhy{lrtmu cr l{nalryol rcrjury rhrr I rn lidn{d r |n ov'\ ii)n ol Clr|rc, 9 ilomNtunu wnhS((r
<br />of lhc Busincs lnd Pn tsions CGlc. en my ltcn$ n in full lnu srr.fi&l
<br />I lrcEby altirm nntlcr pcnaltyol perjury l[d llErc h
<br />s$rd (S... l$)7, Civ. C.)
<br />.ondru.ri,tr LnJirg rgcncr lnrih. Fdnrtunc. otrhcwork tur*hi.hrhtr p-rn,ir r
<br />AEELICANLIECI.A8AIIO!
<br />I Imbyatlmu lcr pcnrhyolpcrjury on. ol rh. iollowins dcclorllions:
<br />D.mlnii. P.mitn^sh.(os Nolirrcrlion F..I€ml R.Suhrions (Titlc 40, Pan6)
<br />_R.quind kner rNdifMto.
<br />I rcnirirhd rh. rcJoalrcr ldrtr,n cB.idinEash.no\rcn!,valnri.rrpdr.hlcn'ihnp3)1..r
<br />hivc rc.dihFlapliialiflrxl drrcihar rh.lh)rc ir,.mrrtr)n tr.or.c! I r8rd r' $mdy qnh rll Ctry lnn Connr!
<br />n..n,thc..hyrnrhorizcrrprcscnl lr!.rrlnsCnyrndCoutrlylo.nrcruFrli.
<br />APPROVALS DATE COMMENTS
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Torqueing
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Sollit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />l\4eter Release
<br />Rough
<br />FINAL l-n-l*bh.ffi
<br />Notes, Remarks, Etc
<br />174
<br />ID/SIG.
<br />Transformers
<br />Sub-Panels
<br />Service Meter
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<br />Dal€:-
<br />L.[i.it Adrt ( _
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