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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE IDiSIG.COMMENTS OV,NER BUILDER DELCIRAAIoN
<br />I hcrchy afiirn lMcr pcn y or p.rjury rh l m cx.npt irun rhc Conrack,d Lkcns Llw aor lhc foln,*ing E!"'n (sc. 70l l 5
<br />Busincss a6d Prorcssion cod.): A.y Cily or Coutrly *hich rcqlnes ! pcmil l. .onsrrucl. 3lrcr. nnprovc, .icnxnish or rcpat 0ny
<br />strucrurc, ,rior lo ns nsuane, ole rcquircs thc q'plicld lor sucn If,rmn kr filc a riemd satmnr rh.t h. ot shc n liccnscd Pu!$otrl
<br />ro rhc lmvisioB .r$. Conlmctocs Li.c.sd bw (Chopr.r 9, Connncrcins wilh Scction ?fin ot Divnion I ofth. auiincss,nd
<br />Pmfc$ionsCodc)orthsrlEorshcncxcmprrhcrcfromsndrhc6osistorrhc.llcsertcr.nll)ri'n Anrvi.l.rionofSdionT0ll5bylny
<br />ryrliconr foropcm sunjcch rhc uptlicod lo acililpcnalryolnor frtrc rhM liv. hundrcd dollds {$50o)
<br />l, * ownc..r rhc lroFdy, .r my cmplotccs wnh wdScs !s rhcn sh conllrcnsatiotr. will do thc qork srd ltr r rms frtr
<br />i cdcn or oncrcd for $lc (Sa.r014- Busincs and Anlc$ioN Codc: Thc Conrracrorr Ltcnrc llw docs no' amly lo 0n owrcr ol
<br />rh. pmFny *h. hnilit\ or itrlltuks rh.mn. and who &{s suh m* hinscllor hcrslror lhrcu8h hh.r hcr own.mplort.s.
<br />prolidcd lhar such imDowmtrls m nor idcndcd or oncrcd for {k lt ,roMtrr. rhc building or imptuktunt h $.ld *irhin lnc Fr
<br />ofconplcrk,n.
<br />'hc
<br />owncr auits will nar llE hunlcn ofl}rcvin8 lhlt fu.r!5c did mr ttiu or inpmk rtt tmpd, ror rh. l,U,ltiE or
<br />-1.
<br />is owrcr ol lh. !tupcny. onr crclusitcly conlrscriis *irh liNn*d conrackn t, .on{ru.r rtE ,,oj.cr (Se 701-4, Busrcs
<br />0ial P|ofc$bn C.dc ThcCotrt0croasLi.cnscLrqdocsnolaFplyro0.o*Nrolpn,pcnlwhobuildsorimpmldsrhoco..
<br />rnd wh. orrrmls f(n sucn pRrirE *nh s G,ni.4bn, li..n*d pur\xan' b rhc (\nkturtr s Lrcnsc ttrwr.
<br />-l
<br />rmcrempl utr{lcr Sccl
<br />Dnie: Ovnerl
<br />lvoR(orsiclmPFNSAlloN
<br />DEqIJA{IIQN
<br />! hcrcby oifirnrundcr Dcnollyoln riuryonc olrhc followiig dcchruri.is:
<br />I havc rlt will minlli. a Ccnificarc oi Conrcnr lo Sciflnsulc for worlcF .omp.n\Jtion. a\ povidcd aor bySclion 3?00 orrnc
<br />Dtn Codc. ror rh. lcrronmmc oflhcwork for which thc Frmil is issucd.
<br />I l{(htrh bi.t-r irnln!!l
<br />^l\\,'l!^tttvh^rsr CF
<br />com!.n\ar ion i'r\urM.c.ari$ uM Fli.y numhcr sc
<br />. .r!6-
<br />t^9Cor3 a
<br />IccniryrharinrhcF.lormrnccofthcworklor*hichthhPcrnirht\ucd.I\hnllR.n'rloyrnyp.mn'nrnymanrcr
<br />so s lo bconE {h]cd lo rhc workc conit.sdri.nIuwsor(:dlirbrnir,Mdr8rccrhnrilIshouldbccoresuhicrt'Ih.
<br />worlcrs conrpcnsnlion lmvisiotrs ofSslion 3?00 otrhc khor Cod..l \hnll, a.nhwirh mq,ly wnh rtns Imvnions..
<br />WARNINi: FJilrc h s.cur *orkcri con'jxr,\xriin, rolrrr|c i\ udl rtnl. nrd drill \uhjd.r rn cn oy.r t,.nmi'rxl nc nlra( id
<br />cnil linc\ ut ro onc hundrJ rhou:JrJ dullds r$lu).0in)
<br />sccrk,. 10?6 ofrh. btltr Cdq inrcrcsr Md slonEy s fes.
<br />''"JUt 16 2018
<br />I h.rcbylllirmundcr pcMlly ol'p€rjury rhar I m licntn rndcr pmvkii,n ofChrrrn 9 (conrrcncinS wilh Scclhn 7(Xl0) ofDivisnr.l
<br />or rhc aurims( ,M PmLsionr Codc- t my liccnsc h in tull n)r.! ond eifccre toea't 6-et
<br />l=1 tcnn-*Jut lt-?fJ+
<br />IAXSIIICIIOIIENDIIiIiACENCI
<br />I hcrcby alinnundcr Fnrlryorpcrjuryrhar rhcrc h a con(fl.rion hndinS aScNy for rhc Frroi,nancc.rrhc sork ror which tht Donir is
<br />issucd (Scc.109r. Civ. C.)
<br />AIPI,ICAILDECI.ASAIIAts
<br />l ltntry aiim u.dcr p.nrlryofpcrjury onc of thc followins dcch,ation\:
<br />Dctulirn n P(onr Asb.sd Norifi.arion Fcderal Rc8ul,liotrs (Tnb 40, Pan6)
<br />-Rcquird
<br />L.ne, ot Noriar..rion
<br />I cLiiiyrhd rhd fcdcra I rcgu lnt ioN ngirdirA ish.!os Enr)Bl rrr nol rtnli.rblc (,rhis Pi(lccr
<br />\L<irfid I|"1rcrc rhh 0l,pliclrn'n nd slrrcrh rhcah,!c inr bomply rirh allCn, rnd Coudy
<br />oidirrn.s,tr srnrc bw\ rcldiDx l{, buildinrcon(ru.ri(r ivc( orlhh City.nd Counryh cnrq !rx,n rh€
<br />rtxlv. f,iri,ndl |m)l.ny for
<br />.\Dplirn l or Aq.nl SiIn lu
<br />-Dr.',,I4d ;fl[nLI6 2[1S
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bondinq / Groundino / UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilinqs (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Bough)
<br />Meter Release
<br />Rough +/t-e/q lrr:i
<br />Service lvleter
<br />FINAL 019/tq, r-,Y) / F-1\.+#
<br />Notes, Remarks, Etc
<br />Air Conditioners
<br />tt
<br />I
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