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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE IDiSIG.COMMENTS OWNF:R BTJtI.DER DI:I,('AR 'IlON
<br />-lhrv.rndwnlmaintsrnworker'conP.nsauoninrranr.,s\rqutc'.IbySccrn'nl7(XJollhcli$orC('rlc.torlhePerfi'ddc'
<br />f
<br />dr. woik l,trwhrhthis pcmir t i My porkcs' .omp.ns,iion nsuru.c *ricr sd |Blky numh.r e.
<br />D\,,'(, \1k19.r!.r'
<br />-Expircs:
<br />/o -( -[\
<br />S.!rrnr rlr76.r rrr l.rlxr (i c, ntd.( inn rt.'tr.! ) rcc\
<br />Ll -t1 2-
<br />DECLAIATION
<br />I h.rcby itftm under F.,lry of p.rjury tlur I am lien{d undcr lrelhion orChaptcr I (drn@nci'rg with Sccli{}n 70001drDivtion:l
<br />df rhc Busincsand Pofcs\onsCoJc. lrj my li(etr{ is in rul 6Ec enl cticr
<br />-[r '?5, rFt
<br />r,,r" '?^(1 -Ll
<br />laBSrSlqrAU.[lrllLGSGElCr
<br />I hcEby ,flnn rndcr pcna[y ol p.ixry rh{ lhcrc is a Llndruch)n Lndins rsee, td ihc Pcribm@. or thc s t'r *hiuh this lEmil is
<br />iss!c'j (Scc. .l(D7, Civ. C.)
<br />AIII!I,ICANI' DE(J,ARATmN
<br />Ilrr.hvrlln,rnLl.r |ttrrhJ_.rt rtr.ton.otdt lnlL.rtrrg(lr.ltrrrtrr'(
<br />l)Lrn.Lrr!)tr P.'n \ Anr(.. Ndntrri(tr) I cd(Ixl R.!uhror\ I l ll ]lr. l'xn6)
<br />Rntntrcrl l .rr.rrl NorLlndn
<br />l.rd,lr_rlHr rhc hdri.' r.! lii Ds '.rILltr'! r\h\nx r.nnr.'lx,.r!!rlltfl.]hl. ri !h1\ tr i.rr
<br />,,lnn. n,.rrntrr,l l)nJl\tY h' nru!r
<br />AIt'lna l or ,\I.nl Si,!nih,m
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Lioht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Lile Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bondino / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Sollit Rouqh
<br />Ceilinqs (T-Bar Rouqh)
<br />It/eter Release
<br />Rouoh
<br />Service Meter / IF|NAL /?// ///7 r
<br />Notes, Rem-arkgEal
<br />'?\./14lt
<br />I hcrchy ,illrn u.dcr ,.nahy of pcrjury lhar I m cxemPr litrh rh. Conltukm l"iccnsc ti* lor lhc fdlowr8 rc$'n (Sa.70ll'5
<br />Burin.$ &i Potlssion Codc): Ary c,ly or counly *hch t qurcs . Fqmr ro co.nru.r' rlrq, inprcv.. &Bnish "r rcp6r di
<br />srocrurc, prir Io ils issuec, abo rcquircs lhc ipplicer ior such Fmn ro [lc d siSned st.lctu.l rhar tf, or shc n k'ns'd ,u^!anr '
<br />lo lhc !$!iions 6l dE Conrnubr's Li..h{d Irw (Ch.plcr 9, Con@mns wilh Sdri.n 7txl0 of Dthidn I of thc Btrsims d '
<br />Pn,icssions Colc) or lhar he or shc is.x.mfl rhcrcfmn and rhc basr for lhc allcscd .x.ry)rion Anvliol{ionofsccti'n ?011 5 bvanv
<br />applic.nr tu . Itmir {biccrs llr lppli€d io a civil p.naxy of fr,| ruE lh{ lrvc hun'ir.n d.I&s ($5Oo)
<br />-1,
<br />rs ovn rof rhc ImFnr. or my cmrloyes wiln wlscs,r rh.t illc d'DP.nqri)n wil dl) llE M,* anl lhc sru!@ ir mr
<br />inrcnlcd oro(crcd fo; sdc (Se.?044. Blrinc*,hd Profc$io.s Co,lq Tlt Conra.rois Licens. tlwnocsnor aml,louowrcroI
<br />rll. lniFny sho bundr or nn{rcB e)n, .81 who &Es tun slk himcl, or hcsclr or lhsuei hn or hc, ow. emdorc.s.
<br />poviJedihsr such imF!rcm s c frn inredcJ orolten l fot ek.lf, howc*( rh. buildiry o. iqrcEtrnr ir sll within onc rla
<br />ol cotrplcrior! rtr Owncr Blil&r wiu haw rh. hnlcn of J,me3 lhrr lE or sh. did mr buiLl or in orc Ilr nn{rrlv for rhc ttFc ol
<br />-t,
<br />a\owrtror{h. pn}pcriy. amqclu{v.ly.o irrlins snh li..or.d of,lr&loF b con{rucl llE [n+s lsc.. ?044. Burims
<br />.Jri Pd(sion Codc: 'I hc Cont!.lois LiucNe Liq docs not apPly to an owrcro, pn)pctlv wh(,builJs or imPnrlcs rhcon.
<br />and *to cdtu B ror such IIroi.Lt w h . Conttulo(, licnsd luEu.nl lo rhc Conrr*toas LienF Lrw)
<br />-l
<br />amcx.mfl ufldcr Ssli,n-. B. & PC. lot this relson.
<br />Dil.r- Oerr:-
<br />WORKERS' COMPENSATrcN
<br />DECLAEAIU}N
<br />I h.rby atlm unds pcnalryolFriuryonc oflhc nnbehr ncbmions:
<br />I h!!c .,n will @im.in r CcnilEale or Con*ht lo S.Hnrurc n)r srkc .tmFnsarion, ai provi.lcd ior hvSeiion:l?fir olih'
<br />Latu Cqle, f{, rhc p.rrormM of lhc *o,L for which rhc Frmit is hsueJ
<br />l.eniiyrhar inrh. p.rlormdkcoirt worklorqhtrh thh rrmir is (\ucd.l shall nor .n'Plov .n, Pcron inanvn'{nncr
<br />b r k b.$m subj.\l lo lh. {o*.s' uompcnsal ion hws ofc.riromi{ M! aa@ rha! ilI shou!.Iktom ixbhd blhc
<br />workcB ompcns{lion povisions orsarion 3?0tr oarhc Lnbt Codc.l sh.ll, tunhwth conlrlv wnhiho* pbvisn'ns.
<br />WARNING F.ilurc !r n!ft workc6'.omp.nsaliu o'v.Bac r unlnwtul.3fll rh,ll $rbjcel m mplovcr lo c.ininal p'mlEs lnJ
<br />civn irncr up lo orc hundftd tlDus{,n dollds (51(x),(xlo), in addirion rd th. (o( of compcnsrrn,r, dlru3cs !s !t!vil&l f'r rh'
<br />o*. j -0-(\
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