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ELECTRICAL-INSPECTOR RECOHD
<br />APPROVALS DATE COMMENTSID/SIG.
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab i Floor A
<br />Bonding / Groundinq / UFER b-zz-l(k"wlu
<br />Translormers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Solfit Rouqh
<br />Ceilings (T-Bar Bouqh)
<br />Meter Release
<br />Rouqh
<br />Service l\/eter (,-t1 -lK Pr.Vm)
<br />FINAL 6-27-lC y,\4w
<br />Notes, Remarks, EtD. I
<br />I
<br />OWNER BUILDER DELCARATION
<br />I hrrchy rf6'n uidcr Fnalty of pcrjury rh.l I mcrcnull ftonr lhc Co.rracn,n Lhctr* llw fd rht follosing rcr$n (S(r0ll.5
<br />Srrincs lnt l,ron$io! C.dc): Aiy Ciry or Counry *hich Eqrndr a p.rn r to cotr{ruc], altcr, ilnpovc. dcnxni\h oi rcl^ir any
<br />dncrnrc. prin ro irs issuancc.,lio.cqunc\ rh.,ppli.inr nrsu.h tEmit ro,ilcn risncd rlllcmnr lh,r hcor shc h li.ctrxcd Pursuanr
<br />lo rhc ,x)!isn,ns ol thc Contmclols Liccnsed L(, (Cheplcr 9. Co nnch.i.! wirh Sc.(ion 7(x)O.f Divhion :l oflhc Butincls and
<br />Pn'fc$i(nrsCodc)orrhatlrorshchcxcmpllhcrcfronrandlhchrnturrhcdltctcdcrc.ll)liotr.AnyviolalionofSsri.nT0.ll5byrny
<br />!pplicsnrior ip.rnn su6rcccrhc spplicsnr ro acivilpcnrlrtotnor frncrhrn 6vc hutrdrcddollr\($5U)).
<br />I.asow.croflhcproFfty,ornrycmployaswirhwascs!srhcirslccodp.nuri.n,willdolh.eorkad6c(rud@i\,
<br />inrcndcn or oficrcd lor slc (Ss.7044. Blri.eri and Pmte$io.s Codc Th. clrnrmcrols Liccnsc tiw docs ml atplr 16,n oRncrof
<br />rhc pmpcrly who brilti or irqm{s rh.mn. and who d@s skh mrk hi rcllorh.rsclforrhr,lBhhi\dh.rown.mnlorccs.
<br />lmvidcd rha! such imprcrc,rcnkemr inrcnd3l oroitcrcJ finsab.li noscwi rhc hiBi'E or imfioromni issklwirhinonc )rd
<br />oa compbtion. lhc Owrer Buildq *ill hrlc rhc bunle. of povitrg rtar he or shc did tut hoill or nrqe( rhc pmpcny for rh€ purlsk ol
<br />-1.!\oencroithcpmpcnr.r'ncx.lu$vcly.onrr.rinA*irhli.ctrrcd.onticlonbconsrruclrhcpniF.r(S..7tB,l,Bu$m$afrl A L\sion Codc: TheCofiNrols Licctrse Lnw docs nor npDlyro !n o*rcr ol fn,F-nt *h{J build!.r im|rovcs rhcrcon.
<br />r d *ho onktrdstor strch p(,jer\sithaco trn,(\) liccn\.d lu^u.nl ro rhc C.nk0ctois l-iccnE trw)
<br />_lrrcicorpr undcr S.did .B & P.C. forrht rc$on.
<br />Da,r ,,**. V 4" o€4 !(:,br6lc(ritENrAlea- lr[claraln]!
<br />I h.rht lrfirm und.r rcn,hy of rcrjury o.c ofth! lbllowin8 dcclarntions
<br />,Lr<e d I o{!(.9)
<br />-lhsvcard!illnsinllinaCrnifi.arcolCon$nrroSclf-lnsuicfdworkcs
<br />conqrcnsalion- as pnlvided tor by Sc.rion l70ij oflh.
<br />Lrbor Codc. lor lhc D.rfoirMncc oflhc uork tor which lhc pcrmir i\ isilcd
<br />-lhivc
<br />sndNiU nrRintain wo,kcs co'nncrsari.tr irxurdh... as rcquncd hyScclion 3?(Doflhc lxbor Codc.Ior lh. rcfoflrttrcc oi
<br />rhc $o for*hthrhtFrnir is ksucd. My wor*c6 .onD.ns.rbn insumre caris,nd plicy nrn$d ft:
<br />l.cdily rh m rtu t rlornuncc ol lhc snrk lhr Bhi.h rhi\ I,c flrir is isskd, I shrll frn cnDby iny 0cB.n in rny montur
<br />$ Nt, ti.com slbjcd b rhc *orlcE conll)cnlarirn hws urcdiror.i0, and tr8rec rhar il'I shotrld bc.ont suhjcct l. ttr
<br />workcfi compcnsarion pmlisn,ns ofSdtnrn 1700ofrh. Lrhtr (1xlc, ! nrll lonh*ilh 6mpl, wirh rho* Pmvkio.s..
<br />WARNINC: l:oilur.lo surc *orkcrs'compcn\lrion mKras. i! untswrxl, Md sholl nrhjccl an cnDbycr k, Lri'nitul,tcnnhic\ rnd
<br />ciril fincs up lo om hundrcn lhoosand dollrs (S100.0G)). in Dddirbn tu th. co{ ol.omFns.lbn. nanuCcs as protidcd for rhc
<br />c()NsTRlJC',rloN I FNnIN(i A(iFrtCY
<br />, hcehy atfir undc. Ienohy of pdjury rhtrr rhcm h a .onsfl.ri,n lcndinS !8ercy fo, rhc l)crfontuft. .fthc work for shich rhn Fmir ir
<br />issucd (Sc. 1097. Crv. C )
<br />A?ILTCANLDECLAMIIAN
<br />I tBEty afiim undcr I'cnrllyolt'crjtr, onc ot'tu tou.wing &cldariotrs:
<br />Dc'mlniotr P.nnilr.Ash.sios Notification rcdcrul Recularins ('l'irlc 40. Pdl6)
<br />Rcquircd kncr of Nolification
<br />I ccnify rhar rh. fcdcral rcBularions Essdins arb.(ovcmvul uc not 0ppliclblc lo this prejcc!.
<br />-l
<br />ccairy rhar I hdc @d rni. lpplicdion {n sllc ltul rhc 0tnvc informlion iscoml.I agm lodrmplywitnlll Cirydnd Counry
<br />od'ramc\ and Srare Lj*\ (ld,ne ro burlrhg con(ru.tmtr .d h.Eby auttnrie ,qvc{.hiiv.s olrhisCilyand Counly ro enrd ulsn l,r
<br />obovc mnrioEi DrcEny r,r in.oc.lio,r{,n *"' l)i, (t13 aeeJ rrQr.c o.,. o9^ly-ltApDrionr or Asmr siEEruR' v 2D 9e\- .-
<br />IIflIiIT
<br />l1)Lict Nnn,h.r
<br />*'T; '[ r"g et^\\ rHeqty (I \.)
<br />LrGNsh.{oN rRActuR
<br />DES.ABAIION
<br />I hcrc'ty rliirm uoder p€nllry or p.rjory thar I am li.cnkrl un!.r pmvnion ofCh&lls 9lmnrEki',8 whh Scdhn 7{xD) ofDivision:i
<br />ol lh. Busincssand Pmfcssk,rCodc. und h,li.cnsc h in tull fore ud.liNt.
<br />t nd.i\ Addrccs:_
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