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ELECTRICAL-INSPECTOR RECORD
<br />DATE ID/SIG.co MENTS OWNER BUILD!]R DELCARATION
<br />I hcrcby rrfinn under Fnalry ('r Frjlry rhal I am crcq)r trom lhc Cinl6cron Liensc hw lbr rhc iollowin8 rc&sn l Scc.7o.r l 5
<br />Busirc$ 8rd Prolcssion Codc) Atry City or Couniy whih rcqutc\ u Fmir ro .o.sflcr, alrd. in rov.. &rhlish .r Et{tr Jny
<br />irdcrurc- nrir lo ils hsumcc. also ,cquiEs lhc amlicitrl for su.h Fcflnil to ,i[ . sismd slltemnt lhul tE or sn is liccnsd puruanl
<br />to lhc pmvisiotrs of rh. Conlraclols Liccnscd tj* (Ch.rrer 9, Commn.in8 wnh S..rio. 70([ of oivkio. I oa rhc Busin.s ond
<br />ltofc$ions Codc) or lhol tE or shc hcrcnrfl thercfrom rnd th. b{sh hr thc ollc8cd cxcmnlion. AnyvioltrlionoiScclionT0.ll.5byony
<br />rpplicanr nn ! p.mn stbidr rne amlicu' ro ! civil n nally ol nol morc lhan filc hundrcd dolld\ (5500).
<br />-1.
<br />.s oqm! ol lhc pmpcn!, or my cnrfloyes wirh wagcs * lh.n rr. .owrnsdion. will do Ewort:ut rft slMlurc is mt
<br />i'ncrLd oro,Icrcd I $le ( 56 70i4. lrusnEss and Prcltsions Code ThcConlr{c1ois Liccnsc Ljwdocsool!ppl}loanoemrof
<br />rhc lmlEny wtu boildr or hl,ft\ rh.m[ n wtr) df,\ $rh m)rt himr.lf or hcn.lt.r rhrcngh hh .r h.r own cmrl]ryfts.
<br />pk,vidcd rnd such itrq,n,tmnh m xn inbndcd or oliiEn for slc lt ln*.Nr, rllc hoilding or inpNwEnl G s,U viitin one ru
<br />nternrrkri,n- ll.. Owncr Builds willh0vc lhe hurd€o ofprcvinS lhlr hc o! shc dil rDt toikl or irprolc lhc pmpcny for lhc puqD* of
<br />l. ,s .*tur or rh. ,ol.ny, afl .x.lurircly .onrr4ring $irh lietrrd c(nnrut,6 ro qNln,cr rhc Fojccr (S( 71x4, Br\i,'c\\
<br />lBl holtsiotr Codc rhcConrracrolsLicctrsc Lrw{brs nor 0ttlyro 0troeicr.ffropcnrwho huildror nrynvcs rhc.con,
<br />utrd who .omrad\ nn su.h flojc.h wirh a ConrBcro(r liccn\cd pusuur h rh€ Conr.urols Li.cn{ uw).
<br />I @ .icnpr undo Sccr
<br />rgttrIiltsraMEdsa:IllN
<br />IECIdSAIIA!
<br />I hcdbyriin r undf fctuliyorp.r.Jury.i..frh. trlk)*inr dcclarations
<br />lhrlc ddsrll Mtr ni'riC.dili(rrcofCon{rnk,Sclfl,\rrcli,sorkr(.1nnnctr\dn[.ns pn,vnlcd ri,r hySccrdr:]7U)ol ihc
<br />l]txrCodr, ntrrhc ptrloilunccofrhc *ork for $hichrhc psrnil i\ issucd
<br />I hrvclnn willnrinrrin *ork.rs .onrNnsnton insunm.. rcquind hy Sr.i ion l7{D of rh. I rftr C,d.. fttr Ih. |frbnrrncd of
<br />rhc sork lor whi(h rhis!drn,ir i\ it\udl Myworks .o?xNdi"n i.$i,m..n*r ud poricr numb.r dc6t/)v+{/trt,,)€(q 7* 2.2-
<br />lccnilvrhrt in rhe pcdornunccin ih. !cr\ {or shichlhh pcirnil t tsucd.l +nl1 nor cn,tl.y !'ry p.6on in anynrnrcr
<br />ii rs ru tE.o'ft \ubjc.r b rhr *.rlcri $nFNarn hw\ of Crlitunir arJ rgfu rhar 1f I \buld bc(nrr subid t) rtr
<br />*olkc^ .om!.ns ion rtuvisia s .f S..r ion l Tm of rhc Inktr C.dc. l \hrll. n,n hsirh (nnfly w irh rho$ pnrvision...
<br />T ARNINC: Ijlilurc ro scurc workcF'
<br />civil fincs !p lo om huturcd rhousand
<br />Smr i.n ]0?6 ol rhc I drr CRlc inrcrc(
<br />n unhwtul d sholl suhjcc' on cmplorcr Io aiminal p.nahis ond
<br />.osl oi.orEnslion. damBcs as rrovilcd for th.--'l,**.]-lt -t{
<br />I hcrcby {fi]nn undcr lfMllyoftcrjury rh{l I am li.cn$d undcr Inov tunorCh,p'cr9(comrmncinS with SNlio. ?000) ot Divhionl
<br />dl lhc Businc$ and Alfc$bns Code. and nry lkcn* h ifl tull nEc ordcllccl
<br />4oz e'7 l;(- to
<br />)
<br />q)NSIAICIIONIENDIMICENII
<br />I teEby .ffirm uds Fmhy ol ,ciury rhal lhm h a oisltuction lcnding 0gcrcy ior lhc Frformrcc oi lhc work for qhict lhis Frmn is
<br />i*sr.d (S.c. 1097, Civ. C ).
<br />ATTUCINIDEgIdEA;D T
<br />I lrnby dfllrnund.r p.nrlry.fpcijxry on. ofrhc folbuing dcchrrrn,[r
<br />lxntlnion P$nrirs A\h.(os Norirr.dini !_.dcral Rcsulation\ ('litle.{}. F.ln6)
<br />Rcqtrncd Lrrrf .f Nrrili.dk[
<br />-l
<br />ccnityl thcfLncro|rcsula|ions re8rdins lst cnos rcnmhl trrc no' l.tricrhlc r()lhh pr+d.
<br />I ccnifyrhj lhdd tord r {rrcr)[ rhciliivc ini,rm i,,r i\ cor.cr Ir!(ar..o dysirhrll(-'iyandCotr0ry
<br />onh r (\and srxrc lf,*sr.hr c.n{rucrnn,.unlh.rchyrurlxtrl/r'rprcsctrrinuof rhn(iryr dCl nyt)cnr.ruNidr
<br />nti)lc nEnrbncd i'ro!.ny nn -0 -&Appli(!nl or ltA0l SiIn{hr
<br />t,rmrilN nnnr ( prinl): :/tZ,4 W\q
<br />Site-Work
<br />Unde rground
<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 />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER 1 '1,U, .4 wrD
<br />To rquerng
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Solf it Rouoh
<br />Ceilings (T-Bar Rouqh)
<br />Meter Release llltllx V,t L{,0
<br />Rough
<br />Service lrleter 7 lrlt€'/rqn)
<br />FINAL 1t ''\lts.,44rl,A
<br />Notes, Remarks Etc.
<br />APPROVALS
<br />Transformers
<br />Sub-Panels
<br />Air Conditioners
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