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ELECTRICAL-INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER BUILT'ER DELCARAIION
<br />I hcrchy rrtr6 und.i f,cnnlry of Frjury rhrr I d exchpr fDm rhc ConrracroF l,i..n\c lj* nrrhc nnbsins saen (Scc 70.115
<br />Busincs\ rM Pmhsn,. C.d.): Any Cily or Coumy which r.allncs r pcrdi nr mn{tucr. ahcr, im[ov.. d.frrhh nr ru|Jtr ,ny
<br />nructurc- pri0tu irs isuancc. !1y, rcquies lhc rptli.Mi ror.u.h p.irnn i. filc a siSn d {arcmm rhd h.or sh. k li.ctr$d pu*uanr
<br />to rh. fmvilions of lh. Conttrcr(r's l-i.cn$d l-,w (Chtrprcr L C.nncmi'r! wirh Sccrnri ?000 ol Dilnnnr I .frhc Borincsr and
<br />PR,rcssions Codc) or rhar hc or shc h cxcmpr rhercriomrnd rhc busis tbr lhc {llc3cd cic'nption. Any viohrn,nofSc.rion'703l r by rny
<br />rlpli.anrlorrp.nnisnbj(srhc.prlic,nrroa.ivilpc.,lrrornorturcrhxnfivchundr.ddoUrsl$r0o)
<br />l- r\ oencr of lhc pmFny. or m, cmpkrrrcs qilh {accs r\ rh.ir $lc onrEnsurn,n. s ill do rhc wrt md ltr (d1@ is ft,|
<br />i c&rrt or orlaid n, $lc (SN.?0r4, Busin.\s and rto,bs\ionc C{xlc: 1!c ConrrDckn \ l -icctrs lls do6 n r rIFIy ro r owncr ol
<br />rhepmFdy sho buildso! in]Ix^!! rhcN.. dld who des s$h so* hiDscllor h.6.llo! rhou8h his or hc! orncmplor.cs.
<br />Drovidcd rhir such nnEovcnrnrs ec nori cndcn or olir.d fn srL.ll lD*cvci. rhchuildintor inlprcKnEni issklwirhinonc F.nr
<br />orc.'ryhri,r rh.Owrcr Boildcr willh& rhc l,lrdcn oltnvirS lhd lE or shc dil ior hoix o, nnltro!. rtc pn,p.iy r.r rhc pL{b{ or
<br />-1.
<br />6s osnc. ol rhc troocny. am cxclu\ivcly c.nlmclin8 wiih liNn\cd ontrucktrs ro con( rucl rtc pnjccl lse.^ 7(!4- Bu\incs
<br />nnd Piofcssi Codc ThcConh.ttr s Lic..sc Law dki n.r iptly i(, r. owncr of pn)lxdy who buildsor nnprovcsrhcrc.n.
<br />and *ho conrrNls lor slchproF.-'r wirn s C.nrrudo(n li.cnscn nuFunr x, rh. Ornrracrois Liccns hw)
<br />I rmclcnrpr uDd.rSccrion_
<br />Da(e Orner
<br />]rcf,TE8II]SIMPINSAIOX
<br />IIEILAAAIION
<br />I h.db, arfirn undcr pc.alry or p.rjory.ft of rhc follo*iry dcchorions:
<br />-\I har ud $ill tuinhin a Ccrr ificarc o, ConE n, Sclt lnsurc io. Forkes conrf,n{rion. as pFvidcd for by sL{ion 17fl) or rh.
<br />Libor Oxlc. aor rh. pcrf(llmrcc oi rhc aort for which rh. Frnril is hsucn
<br />h[p.1n L1F.u.d M,wo't.'. . mFn\J! i,,n in(umfr'. ..'n n Jdl$l'!ynumh.r m
<br />?T(z-
<br />"^or*,^*,,-@h:-( 1- tL{.6 e,pr* 6-lk'
<br />I cdify rhri in rhc prrlornbtud ofrh. work fff *hich rhis Jr.iinir h i\sucd. I \hrll nor c'npk)y rny pc^on in rtry mrtrrcr
<br />so !sh b.(nrc subjcct to thc Mrkcrs, con[cns,iion kws olcllironri( rnd Uc rh|l if I {urb bccom shjcd k,llrc
<br />wolkcr .oolc.sation lmvhi.ns of Sc.riotr 1700 of rhc tihtr C.dc. I shnll. loiihwirh colnply pith lho{ pmvhions
<br />\1ARNIN(; Frilrr k) *.ure $orlcr\ conl^-n\rrn,,
<br />.nil linr\ r| r, o.c hundr.d rho!\rfil dollu^ tSl(X)
<br />Sc.ri(n:1076ofrhc l-rhtrGxlc. dcrc{ n dnnorncv \
<br />rh,r: \ - / /-l {nuor,-.,.
<br />corcr8c i\ dnlnuful, nnd \hJl suhj..r nn cnplo!$ lo rimiml pcDhas Dnd
<br />add'riols'h. 6{ or mmp.n$r'on. d.nE8.s r\ rD\idcd rn, rh.Hr--
<br />DECI,ASAIIOX
<br />I h.Eby rrtrm undcr pculty of pcrjury lhar I am lianed undq prcvision ofChoplcr 9 (ommrcins with Ssri,.7ux)) orDivision ]
<br />o{ th. gusirc$ ond t\ofcssions cidc. ond my ltcns n in tull lb.a ad cfid.
<br />c-(o oY$4 7tya-r-"-,\
<br />C(INSTRUCTI(}N LFNDI:\(; A(iFNCI
<br />I hcrcby ofirm undcr FnaltyofFrjuryrhur rhcrc is a coD{rucrbn lendirs aacn.y f(r ihc Frfornrn.. orrh. w.rk ror shhh rhh lEnnil is
<br />hsucd (Sc. 1097. Civ C.)
<br />AIPIJSAALDEIIASA.IION
<br />I h@t'y ifm lndcr p.tr.hy ol qcriury onc olrhc followine dcclaralionr:
<br />D.molirirn P(. k sh.sos Norin.nrion Fcdcrrl Rcgubrion! Onl.40, Pan6)
<br />Rcquircd ldlc.orNoificrrion
<br />-l
<br />cenily lhat thc rederal rc8ulariotrs rcEudin8 &rbcslos ictrxtrul are rer trpplicol,lc lo lhi\ nrJj.{r
<br />-t
<br />errify rhor I h€lc rcld lhis applicrtion !d slarc thor tlE rtnrc informrion h corer. I acr ro Nn ly wnh,ll Cily.nd Counry
<br />ndmamc\ and Stlrc tjwi rcbrhs r. buildins mns!!EiaL!$ h.rchy luthor iu c rFesnrxrn.\ nl rhn Cny rnd counry'. cn'n ullon rlEffi,-^ffi":"'ryff De,? r*LZ-v
<br />P.mirc n,ne rprrnr,: {al: k-
<br />Underground
<br />Pole Bases
<br />Lighl 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
<br />To rquerng
<br />Sub-Panels
<br />Roof To p Equipmenl
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rough)
<br />I\4eter Release
<br />Rough
<br />Service Meter
<br />FINAL 6nfl 7/ .21 +14r-)
<br />Notes, Bemarks, Etc. t I
<br />APPROVALS
<br />Site-Work
<br />Transformers
<br />Air Conditioners
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