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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS ID/SIG.COMMENTS OWNER BUILDEN DELCARATION
<br />I h.rcby stfirm udcr Fnahy ot pcrjur, rhul I m ciempr iiom rhc C.nra.bF Lic.trs. bw ior lh. followin8 rcasn (5(.'.?031 5
<br />Busiic$ !M Profe*ion Code,: Any Ciry o. Cou.ry whi.h {quies r lrmit lo cotrndcl, alts. improlc. &m,hh 6r rcpan lny
<br />nrudud. pri.r b irs issuakr. alm rcquircs thc 0prli.ant ior such pcfl l ro lilc a sisned rhrentnr rhlr h.orsh. h liens.d l)usurnr
<br />ro rhc rrovhinns or rh. Conk..roai Liftn*d hw (Ch,flcr 9. ConnmNitrg wilh Scclion 70m oa Divtion :l orrhc Businc$ dnd
<br />Pn,lcsntrs Codcr or rhrr h. or shc r crcmDr lhcEfionrlndlhc hosh lor rhc llkscd ci.mprbi ny violariooolScclionT0ll5 t, any
<br />rdllt,-n,ri., nn",.n *r'l(*,hc omhu;l'n a.i,ilI.trulr) nl'nor m,'R rhnn,'vr hdnJrJdullo^rlroo,ht\v, I laotrftrnrrhcF'Fnr.^rmyc'nnh'trcitr h wrecs ns rnct snc .onlrnsulion- will do rht wolk srl rtr strtm is mr
<br />'inr.ftld 'rollcEJ ror solc (Scc 7(},la. Busi'rc$ ond Profc$ions Cod.'l h. Cont.c'or's Liccnc ljw dcr nor rpdyio o*noor
<br />rhc ptr,r.d, who buildsor nryows rtr@n. ud *ho drci srch m* hinrclf.r h.r*lfo. rhouBh hh or hcr o$n enPhrecs,
<br />p,ovidcd th.! such inrItrormnh @ nor inrcndcd or .ns.{ roi {lc ll lk,wcE., lhc buitlinS or inpmrm is r,l1 sirhin onc )td
<br />orompkrion. rh. o{nfi Buildg *ill h,n rnc burd.tr ol pmlnE rMr L or sh. dn ml build or itrwove lh. pnFrly ror rhc ,urrsr of
<br />l. $oqncrol(hc J,ro$ny. rnrexclusivcly conl!!(inr wirh liccn*d conra.tm ro cofsdd rhc trojcd (Ss. ?(I44. Bu$nc$
<br />md holt$irn Cixlu:'l h. G'nrr&ttr s t-i..n\c Lna docs n.r at)fly tu rn owncr oinropcnysho huilds nr i,npn,v.s thcr.oi.
<br />,trd wlr co n.k for such pm].cts sirh a Conracto(s) liccnscd lunurnr ro rhc Conr&rois l-i.rn{ Irw )
<br />I turcby alirjn n.dcr pcnlhy ol pcrjlry onc ollhc,nlh$ing dcclaralion\:
<br />I hrvc rndwill mdintain . Ccnrficdc ol Consnt toS.lf.ln(urc lor worker' compcnsd n& a\ pmvincd fr, byS.\lion 1700 ollhc
<br />ljhtr('dlc- forrhcpcrlontun.corrh. work for qhrhthc !.nnit h hsucd.
<br />-l
<br />halc rnd {ill mri air wortcr conlncnsaiion insumncc. rs rcquncd hyS..rior]7mollhc b6or C(\lc. nnrnc p.rnn'rir.,ir
<br />Ihc work hr *hicn rhis lcrnrir is issucd Mysorkc^ .unprn\ nnr ii rnr.c.,nicr and lolicy nnnrtcr c:
<br />ad,;ffi .n,tl,,y rny ncr{'n i', my rr trci
<br />\houllh..oN nrhlcd ro rhc
<br />$orkc6 comFn\arn)n F,vi$ons ofs.rri(r 17ft)ofrhe Lrlx, Codc.I rhlll. tunhwirh c.nrtly w,rh rl$$,rovisi(rr
<br />WARNING: Failurc to ccurc workcr coarEnsrrion..tcrryc is uihstul. rnd \hrll sohitr .n cmploy.r ro dinriNl ncnrllics and
<br />civil hrcs uf t0 onc hunnrcd I
<br />:._' lahf
<br />I h.rby rllt'nunJ.r Ixnalryofprjtry tld I rtrt licutrwl uddcr of ChrDIcr'J (.onnncn.i',8 *irh
<br />ol Ihc Blsimss.nd Pofcsn,nsCodc. a nry licci{ h in iullrt
<br />IONSIf,IJCIION.LENDINCSCINCT
<br />I hcreby affirnundcr pcnalryorrcrj!ry rhnl !hd. iq,.oNrru.tbn hnding.Scmy hrlhc pcrforron.c of'hc worx for whkh rhk rsmir is
<br />ksucd (Se 1097. Civ. C.)
<br />AIIUCANLDECI.ABAII!]N
<br />I hcrr,y otrmr und$ p.nlhy ofpcrjuryoN of lhe followin8 dslaErions:
<br />D.mlirion P.rmirlAsb.rros Norifi.ation ftdcrrl Rc8ulat ions Oirlc 4.0. Pan6)
<br />Rcqun.{ L.tt r of Nolil_Etion
<br />ltr1,J
<br />ilrrlBr rhc fcdcral rcsUl ionsRgard,n! an{io\ rcnk,vrl rc mr rt'flcrblc lolhi\ nnr.rr
<br />lh!l I hrvc r.ad rhisrplli.rri(u dilnr rhrr rhc rb.vc nrfornDrion ircorar I asrd r. cor'rly wnh dll Cny ali Co
<br />.nntrtr0..\ rnn SrrrrI xs\ rIri'€t) hui i']!
<br />rhovc nrnrioN Doj^-ny lnr insfd.rtr,,!trrfli
<br />t,rizc rcprcscnn ik\ orrh
<br />ADpli..nl or t6l Si,tnnlurc
<br />Pemite nrm. (prirl ):
<br />'t'i,")j
<br />/D
<br />Site-Work
<br />Underqround
<br />Pole Bases
<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 / Groundinq i UFER
<br />Translormers
<br />Torqueing
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Bough)
<br />lVleter Release
<br />Flough
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<br />FINAL L OL fl K#\81
<br />Notes, Remarks, Etc.-t
<br />DATE
<br />Sub-Panels
<br />Servrce lvleler
<br />;:uli)
<br />Irnd as Ad.lrc<\
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