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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG COMMENTS OWNER BtI!LDER DELCARATION
<br />I hcrcby 3f6rn1undcr lcn,lry of Frjury thd I !n crcnrlr lrom rh. a, racloB Lic.n{c Liw for rhc n bwin8 rca$n (Sc.70315
<br />Businc$ !d Prolcsion Codc) Any City or Cou,ty *hich rcquncs n tcrnrit lo con(rcl. allcr, inurolc, dcn,lhh nr rclon sny
<br />sru.l8c. Eior ro ir\ issuak., als rqxirc* rhc dptlicanr (tr suchtcmir k,lilc d \igncd {brcnrnr rhai h.ur rhc h li.cnkd puisud
<br />ro rhc pmvni.trs oflh. Conlmcl.ls Liens.n ljv (Chopr.r 9, C.mn.mine wirh Sc.lion r(]0O of Dilision 3 .f l,'c Btsincs an!
<br />PbrcsionsCodc)orrhar h.orrhc !.ieorr rhcrcfrom lnd rh€ b!\i for rhcalkred.rcdpliod. Any vk,l,!ionorseri,n T0ll.s byany
<br />npplicad for a p.mn subjccts th. rpplicant ro a .ivil p.mky .l nor mrc rhu nvc hundrcd dolles (S5m).
<br />-1,
<br />rs owncr of lhc proFny, (, ny cnpb)e\ {ilh Buscs 0s thcn ync conDcnslrnrn, *ill do rhc wot aid lhc srMurc i\ ior
<br />i .Mcd or oflarcd f.r elc (SN.7044. Busin.sr dnd ProLsions Codc l]1c C.nta.rof 1 Li..n* tis docs n.lamly to rn owrcrof
<br />$c poFny wno hlilts or imposs r['mtr ad who nB sEn s* linrclf or hc&ll or rhou3h nis o, hcr o*otmplorccs.
<br />prolid.d rhar su(h impomNs @ rht inrcnd.d or.ff.Ed fo. sL li h$rr. rh. tniHin8 or in{,mwmnr is {'ld {irhin.nc F.r
<br />oacotrpk b., th. Owftr Build.r will hr!. ilE hurdcn of t o!in! rhd h. ur rhc did mr toilll or inpmw rhc potdy for th€ luqns of
<br />I. n(ostrdr l rhcpn,p.at. rtrrcxclu\ncly..nracrtrg sirh li.cn{d foftrcrr^ h .oNtucr rtr o(ic.r (scc 7(x-{, Bx\i'trs
<br />afrl thr'c\\in(i'dc:fncCo.lrrlorsl,iccnrcLnwdoc(trorrttlybanotrncr.It',o|xn,rh{,huildrorn.prove\rnercoD.
<br />!.d vho .o kaLr\ fr :u(h pn,jc.rs sirh a Gn Dcr.n r liccn{d purshtrr ro rhc Cunkrtn-s Lkcns liw)
<br />I d.x.mpr undd Sdt,n 8 & PC lnrrhi\rcJvn,
<br />!I.}8f,8&S:TOMSENIiAIAN
<br />DECLAM.IJA!
<br />I hcrcbyaIfifln trodcr pcnahyof n rjuryonc orrh. folbwing deldorions:
<br />Ihrlcrxlwillnri.hinNCcnili.rrcorcon\.nrt,Scllln\rtur{nworkdscorp.trs on.N pr.vidcd Lrbysccli{r lT(x)olrhc
<br />Ljllr Cdq fir ric pc.io!@ice o t rhc wo* for stth I hc rcrnir h i\su.d
<br />I hav. rnd will m.inrain w.d.ra ..mFns i.n insuirn.e. r.qxiftd by SL\rbn l7m olrh. tjtu Ord., for lhc pcrlilirMf,c of
<br />ihc workfnr which rhis ,,.rnir is hshd Myuorkss comp.nerion in\urincc.anicr 0ndF,liynun rcr u.
<br />-l
<br />enily rh.t ir rhc l)crLnmtre of rhc tforwhi.h$t pcirnn k i$ucn.l sh.ll not enDloyanyrnotr in any nEnnct
<br />$ r\t) h..oar {'hF.rr. rh. $orkrrr cor|rn\dntr, h$r oi Calili)(rir. xnd r!'.c rhi ll sh)uld h(conf, \uhjLr|orhc
<br />i\ unhsllrl. d shrll subic(r rn.nDl.rcr ro aimiral n rrlri! !trd
<br />civrl tlms un u on. hundrcd rhousaid dolles (or.omp.nsatn.. dlnEBcs as rmrmcd lnr rh.
<br />S.didr 1{)76.rrh.li,litra.. i' cr.{ Mn ari
<br />,r",' Qf o\.\9.,t'lrl( l. \( \ I l()\
<br />I hcrcby afinn ulldcr Fndryofprrjury rhnr I afr lietra{ utrdcr Eovi\ion of(-}+rr.9 (conrtncing wirh Sc.rbn 7m0r olDNision l
<br />ol lhc gusincs md Pofcsn,ns Codc. ud my licensc is in tull lora aRl cl,fccf '
<br />@,(2o La>\buqL1!)f@
<br />*
<br />u,#-
<br />C0!,IIAU.(:IIANIDIDIIC.AGII!(I
<br />I hcrcby rfllnnrndcr p.nrlr!ofp.rjur, rhar thcc t. $ndtucri,n hndirf rgcr! for rtu l.rfonmmc olrh. mrk ior shich rhis pcnnir h
<br />k\r.d (Scc :1007. Civ C )
<br />A!zucAI{fDEclrtxAlLQN
<br />I lEtby altm unlcr pcuhy otl)c jury oft ofthc aollowins d6lodnn,\
<br />Dcmlnion Pcrmi's Ashe$os Nolirrcolnrn lcdcrll Rcruldions (Tnb 40. Pnn6)
<br />Rcquir.d t-crr.r ol Nolilicrrior
<br />l..nifyrhrrrh.fcJcrrlrcguhri{,\mgudingr\lx{osrnx)slrrcnorarpli.rbtn)rhi(rrolc.r
<br />-l
<br />ccnili th8t I hNc rcad rhk npd icurion ud {0rc that lhc ntn$ irntrnd ion k cotr cr I a8re ro onrply *irt all Ciry ad Cotr y
<br />odin(nccs and Srntc L.*srclding inE conslru.ri,,n. rtu hcrchy trurhorizc rcprcscnr!rirc\ ofrhis Cn, trnd Cornry t, drcr u,a)n rrt
<br />drivc nrcnliomd 0n)ncny ror in(
<br />,1l,plir nl or.\rul Si,:ni PIot-tg.,
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Satety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />To rquerng
<br />Sub-Panels
<br />Roof Top Equipment
<br />F actory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rough)
<br />Ivleter Release
<br />Rough
<br />Servrce Meter
<br />FINAL 41nil4 n .{nw4><1 D-/
<br />Notes, Remarks , Etc.
<br />'l at
<br />Under Slab / Floor
<br />Air Conditioners
<br />I
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