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APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />S pas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soflit Bouoh
<br />Ceilings (T-Bar Rouqh)
<br />Meter Release
<br />Rouqh h/L(nK s\ 4,
<br />FINAL 7/7t/rt >D 6b
<br />Notes, Remarks, Etc
<br />o
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<br />ELECTRICAL.INSPECTOR RECORD
<br />OWNIiR BUTLDI]R DELCARATION
<br />I hcrcb, afljrm undcr pcnrlry of rrjury lhar I om cxcmpr lmm lhe Coorracro6 l-tcnsc La* i(tr rhc rolk,sin! 6,ii (Sc..?011.5
<br />Businc$ al]d Prolc$ion Codc): Any Ciry or Counry which rcqrncs r pc.on n, .oi{ru.r. llt r, inDir'vc. ih'relhh "r EtEn rny
<br />nocurc, prir to irs issuarc, lho rcquircs rh{ +pli.anr f{n such pcnni' r. fil. a siln d Mtnmr rh,t lt or shc is liccrrd puFu l
<br />ro th. nmvisions of lh. Conr.clols Li.cn*d tiw (Chrprcr 9. aonmrcncin8 wilh Sccrion ?000 oI Divi\ion I nrrhc susinc\s nnd
<br />P,oltssi,rnsCodc) orrhrrhcorshc iscrcmpr rhcrcfrom( rnebark forrhc altscd crc'npii.n Anyvn,hrionorSoli(]n]0ll.5byony
<br />rmlic.nr ror a r.nnn suhjc.hrhc trftlic0nt lo 0civilNn0lryornor Nmlhrtr fivc hundrcdd.lllm (S5{X))
<br />l. ds oqncr oirhc pn)Fny, or my.mpk,yc.s wilh w,Ccsrs rhct vrc.annpcnuion. rvill do lhc work and rhc slMrurc h nol
<br />lntnd.d or of.r.d for elc (Se.7O1i, Ausincs and PmLisnrns Gxlc: Ihc (b.nador's Li.cns ti* doc\ nolqrplr ro !n own$ of
<br />lhcpntrny *ho huilds or impmrrs lhcmn. ud *ho des se-h so* hinrcllor hcnclfor lhou8h hh.r hcr ow. cmtloy..\.
<br />tlr.vnid rhar su.h i pnrrcnEns tnc nol inrcodcd or oliqcd nn st. lt ho*$cr. llr hoikliig or idpokr i\ $ld *ilhin un( ,tr
<br />olromptri.n- rhc Osncr lruilic! *illhlvc rrE hurd.n ot provin8 rhrr tE o. shc dil mr h'ili., i,qrorc rhc pmacny li,r rhe purrrE or
<br />-1.
<br />r\ owrcr of thc lnrlEdy. rr crclusivcly conkr.r in8 *irh liccn*d .otrkrclor to c.n(rucl lhu Ilfl jccl (Scc 704.,1, Suak*
<br />Md PRnssbn Codc: 'l hc C.hrkkri Liccn\c Law do.q nor ,t,t ly b n owncr .f Frpcny who buildi or inprors rhcr.on.
<br />rnd who ontmds rbr such rrreJccIs wirh r Conrractorlr) liccned puru.nr ro thc ConrBcrols t,iccnre kw).
<br />-l
<br />anrcxcnrfl undcr S(tion-. B &PC forlfihrcasn
<br />Dele: oencr.
<br />wonxrqs' coMPENsaTbN
<br />DECIAf,AIIO!
<br />I h.rcby firm und.r pcMllyofprjuryorc oflhc followin8 dclralions
<br />-l
<br />havc &n will nEinr,in. Ccniarcalc of Consnt lo S€lf-lnsurc for woftcrs comllensrrion,!s pnvidcd f,r hysccrio.1700oirhc
<br />ktrtr C.d.. for rhc Frfitrtune of rh. *.rt for which rh. ,xmn is i{sucd.
<br />-l hovc aod will mintaifl work s comrcnsalion itrsramc.0s rcquncd hy Sc.lion 1700 ofrht Ljb.i Codc, ror lhc FfornuB. of
<br />lhc *ort ior shichlnhp.rmn is is$ed. Myworkss omtcnsalion insucncc cMicr ajd llolicy.lalxi ml
<br />' E,r,tur,,". /a.,rr. /-s
<br />' 6o?zE < -:'2 z"/e/r
<br />lccnily rhrr i'r rh. p.rlbrnuncc ofrhc $ork h)r wfikh rhi\ pcrn,ir is i\\ucd. I \hall tror c'nploy dry tcrsotr ir iny Danncr
<br />\o rs h bcL_om suhjcd k, rhc workcn compcnsir or l.* { or C,lilo ria- ind uB rhd !r I \houkl hccom \ubjccr t) rlr
<br />sorkcr.onlFnsarionrmvisions.fSccrnrn:lTlDofrhchtryCodc.l\hall.ri'nisirhconplt$irhrh,rF)risnr\.
<br />WARNIN(;: Frihrc k, $.urc wortcr .oDp.trsriron.o!crd!c rs unlatrlul. ond $(ll suhjccr .n cnrplorlr t, oi'ni'd pcMhic\ a
<br />.ivil rinf\ tr|] ro otu huidtud rhor\r d {lollr^ lll(x).(xl(,
<br />Sccri(n,:1076olrlrc lrhtr C{x[- drrc(nnd dktrnry'\ rc.\
<br />i,r. drn!Ac\ r\ tn,rnlcd ntr rhc
<br />a/,ey'r
<br />I hcrcby nlfinnuMcrynrlryoipcrjuy lhll I .m liccnqlunder prnvision ol Chlnlc. 9 I corftnci'rc *irh s.dn,n 7fix)) oI Divi\id l
<br />of rhc alsincssnnd Pn,lc\\t,ns Codc, dnd ny lk.n{ i\ in fullror.c dtffc.r
<br />3 ,/o 5z 72ry'(/e .-,
<br />CAXJiIBUqIONIIJNDINC.A(iIINII
<br />isruLYt lscc. 3l)9r. civ. (.)
<br />ATTLICANLDECLA.BAIION
<br />I ho$yufimunderplnallyolpcrjuryonc.lrhc nnbwinr d(larlrions:
<br />r)cnnlilion Pcrmir*Ashcnos Notilication ltdc.{l Rc8ulllions frnt tllj, l'rn6)
<br />_Rcquircd txrrc! ol Norifi c:ri.i
<br />ilyrhrrrltr ltd[r!rcgulni,nNrctnnti',I r\b.no\ rcfk^]lr.c norrt,ph.nhlc k, r]N fn'J..r
<br />rr.orrrcr li!rcc b c.n|]iy sirh xll( irt rn(l(_,trt
<br />n..\ r d 9d.lj*\ rcl ingt0 buinlinS rcFeEnr.rivci ofrtis Ciry rnd
<br />- D.r. .
<br />at-rc trEnrioncd lrepcny lor iNpcclion p
<br />,\pplictrnl or Agrnl Siuntrturc
<br />P"-' * n"-" rp.inrt, X 2"ar.t6trZA-
<br />Air Conditioners
<br />Service lvleter
<br />"/,</z
<br />I
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