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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS O1VNER BUILDIR DIiLCARATION
<br />I hcrchy aflnm unds pcnalty ol rrjury rhar , am crcnDi fom rhc C.ntroclor' t,iccnse L!* i(tr lhc folbwins rc0etr,(Ss.70.11.5
<br />Busincs ard Profcsion Cod.): An, Ciry or Counry which rcquirc\ ! F,mir ro .on{dd. alro, ihpiow. d.q)lish or rcp.it uy
<br />{d.tur.. Eir tu irs isuftc. rko Btui(s rh. rppli.dr for ruch Fmi o fik r siBncd $mcnrnr lh.l h. or shc k liccnscd pursulnl
<br />io lhc povhions ol lhd C. racroas Liccnsd Low (Chaprer 9. ConmrhcirB wirh Sc.rion ?UD of Divhion 3 ofrhc Busincss ond
<br />Pmfcssiofls Codc)or rhat hc trshc is cxcm lncrcfromandrh.tEsisrorrhcrllcS.ncxcnl,tion.AnyviollrionotSsrionT0ll5byDny
<br />atpliclnr for a!.rmilslbjcclrthe ltllicanr ro acivilrcnoltyofnot mrcrhon fivc hundeddouon ($5m)
<br />-l-
<br />os owncr ol rhc pmpcny, or my cmployccs wilh waSci ,! rhcn $b compcnerion. will do rhc Eort dlhc\rd1urcis tur
<br />inrdntn or olitrcd for $L (S( 71}14- Busincss ond [,rcfesstns Codc: tnc Conrsch \ l-iccnsc ljs do n.r apnly to an.wnfiof
<br />rhc ImIEny qho hoilds.r irq'm$ lhcNn. arxl wltl des skh M him*lforh.rs.lforthmuEhhisorhcrowncmplolecs.
<br />provid.d rh sxch ihprow rnk tm nor inrc lcd oroftcrcd for sab lt ho*ss. rhc huihin! or impmwtunr h $ld wirhin onc ]etr
<br />ol.oq,leri{nr. rhc Oqncr Blilds lill hlvc rh. tntrdco olpmvitrE lhdr hc or shc d Bn noi! or i'q"ov. rhe [a,pcny ror rh. pu4M or
<br />l- arowncrofrhcpn,j^-ny. !nct.hhivrlyconl.lclin8*irh lien\cd conlrrclor r{) .on(tud llr rmiccl iss 7l}r4, Burinrs
<br />rnd lh)lssi cod. rhcconkr(tr's Li.ctrsc Law dfts ior upllyk,.noqncr.lFropcnrwho buildsor improvcs rhcrcor,
<br />3nd who.-onrBrsli,r\khrmjccr\wirhrCoorBdons)liccnsldpurulnrrorhcConra.roisLiccnyuw).
<br />I rmu.n,!r uDJ.r Sccri,'
<br />,,," slt,ltt
<br />I h.rchy !rfintrundcr lEn0lly of p.rj!r, onc ofrnc n'lbuins dcclorili()ns:
<br />lhav.ddsillnuinhi..Ccnifi.nr.ofConscnrioS.lflnsrrnn*.rkdscoryrtrsrinr..strovid.dfttrbySsrion:l7rx)olrhc
<br />tjbd C.dc. f{n rh. Frformutuc ofrhc {ork ln whi.h rhc pqmir i{ k\kd
<br />_l h8vc end will mrinroin worker compensrti.n insuritrcc. is rcrtuncd br SNr ion l7m of lhe l,bor Codc. aoi rhc Ixrrortumc of
<br />rhc work lbrwhichthis pcnnir is hssd My worlcrr .ompcNarion iNnr.nccqrtr mdnolic] iuoficrurc:
<br />Pnl'cvNun,trr knn.s:
<br />I ccnifyrhJr inrhc pcnonnanccofihc *ort f{n *hi.hrhis pcflnir is hsurd.l \hallnor cnrpk,yantF^oi ii rnynmncr
<br />$ r\bh.onf, suhi\rr) rlr solkcrs .onfc.\.ri l,s\ or crlir{mir. mdr!rcc rhd ilI sh.uld hRnnE ru$jcci hrh.
<br />work.rJ compcisrtn'n pn)vnn,i\ofSe.rion 17(Xlofrhc Lrhr C(xlc.l \hnll. fonhqirh conll'l! wilh lho{ povhnn$.
<br />W]\LNlN(; Fdlurc ro wurc sorkcB'con{cnsarn,n ovctu!. is utrhwtul. rnd fiill nrhjd {n cmplorr lo oi'ninrl pcmlrics trnd
<br />civil fitrcs I lo onc hnndrcd lhousand dollrs (llul.0u)). ir.ddnion t,rhccosl oi conDcnslrion- duugrs a\ prolidcd f(x ihc
<br />Sftri.n 1076 .f rhc I itrr Crxlc inrcrc{mdx .rrcv'
<br />"",,-51.1.t- L-L Appu@,,
<br />I hcrchy aflirm undc. I]coalrrotpcrrrry rhar I um litrnsn ondc. F,visioo .r Cnnpro 9l.onmmnrB *nh serion 7u[) olDirkion.l
<br />ot lhc Busincssund Pdis\insCodc. lml nryliccns is ir lull turcc ond caiccl
<br />c0xsrBucr.lQttrlluNc-&c!!1lr
<br />I h$chl,rfinn und.r Jrnrlrt orp.rjury rhal rh.re h n con{ .rnrn b dirS rgcky tu rhc ncrlor.Dncc oithc so* nn !ni.h rhis pcrnrir is
<br />k\ucd (Scc .llrr7-Ci\ C )
<br />ATILICAILDEgIIIAIII}!
<br />I hcEby afrim und.r Fnally ol Frju,y om of rh. lolloqing dccldrl ions:
<br />D.rmlilion Pcr6n$A3b6los Norificarion F.dlml R.Eularbns (Tnb 40. Pd6)
<br />-Rcquircd
<br />tdl.rof Norifi calbn
<br />l.cdilirhrr rl,clc crrlr+ul i(' s rctddi'rg rslrr.\rrntr)vrl r. or l,t)l(ihlc io rlrAJior.cr
<br />-l.cnilyrhar
<br />I hrE rcd rhis trptlic0lion ad shrc ihdr rhc atx'vc itrlntrtrtio. is coftccr I a8m ro on]Ply wirh all Cny nnd Counry
<br />ordinrn..s.nd Sralc tiwsEhlingro bundin8 .onsrDcrion, md h.aht.nrhoizc rcpresc otivcsolrhhCityandCounryr.cnrcrrlr,nrtr
<br />rhrc rnri{nrc(l niop.ny ntr i,,s
<br />Appliunl or AEenl Si*nnlurc ^*,1/?l!4
<br />Site-Work
<br />Under ground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lite Satety /Low Voltage
<br />Fire Alarm / Dampers
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Translormers
<br />To rqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />lactory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rough)
<br />lvleter Release
<br />Rough SlLqlt9 T*?7
<br />Service lVleter U
<br />FINAL Ieblll T-,t ,r't'r)
<br />Notes, Remarks, Etc U
<br />Communications Cable
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