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ELECTRICAL.INSPECTOR HECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNEN BU!LDEN DELCARATION
<br />I ncrcb, rtftm odcr pcmlry of pcrjury rhnr I m cxcnpl frcnr the Co"rr&lo6 Liccns L!* for rhe iolk*ins rcav,n lsec 70:1 1.5
<br />Bx\i.c\t 4d Pnnt$iu' Codc): Any Cir, or Counly whiLh .cqutcs ! lcmir l(, conilrucr. dlr.r. nr'tmvc. &fl,lilh or qEir iny
<br />\rru.rurc. pri(" tu irs isuane.,ho rcquirer ihc lpplicunr lu ruch penrir ro nbr sigtud sd.m r rhd hcor \hc is licen$d lnNU n
<br />l. lh. pmvnions o, thc G,nlretols Licenscd !i* (Cha, cr 9. Commcncin8 with Scclion 7(DO ol Divhio. I of rh. Btr\incs and
<br />Prorcsli.nr Cod.) or rhar h.orsh. k crcmpr rhcrcrod md rhc bn\is (, rhc slh8cd .rcmprbn. AnyviolsrionofS..rbn 7011.5 by my
<br />appli.anr lor uFrmil suhjc.rlrhc rrpli(lnr to.rivilp.mlryo,nor fttrc rhM rivc hunded dolltrs(3500)
<br />I. ds owncr of rhc pn,rf,ny, or mt cqrloyEs wnh wagcs us rh.n sk.\,mpcnrn..n. willdo fi. woik flld thc srL]1urc k mr
<br />inrend.d or olttrcd ror slc ( SE.7(x4. Busircss lnd Profesions Codc: Tlc ContEcror's l-kenr l!* does nor +plt b an owtur ot
<br />ih. FDcay *tr) hnilds Dr in{mws lh.Nn. and wtr) dNs ruh wrk himsclf or hcrcll or I hou8t ht or hs own cmplorces.
<br />nrovidcd rhor such nnpmrenr.rs m mr inrcndcd orofi.rcd lnr s"k lt howc!.r, rh. triLli'{ or nr'rbhmm is $h wirhin onc Fa
<br />of€omfhlion. lfu O*rcr Buitlcr will htrv. ltr bunlM or tovin! lhot h. or shc did ml hild or inpmve lnc pmrcny ior the pu{bs or
<br />l. ns o*ncr or rhc pmttry, am crclusivcly conrdi'rg wirh lic.trscd eNradon
<br />'o
<br />.oniruct rh. l)roj$l (Scc ]O1,{, Bunmrs
<br />.nd ?FflarionCodc:lhcConrr.clol{LiccnscLosdcsnolnt,,lylo{noqncrolropcnywhohlildsorimtolcsrhercon.
<br />ri'l sho $nrDcr\ li,' \!ch pn+.h *irh r GxnBcnni, li.cn\.d puruJ n'rlrco
<br />lrsrc b
<br />DECLrtBAIlol!
<br />I hcrchy urlirmundcr pcnrhy of pcrjury onc ofrhc |ollowin8 dRloraln,ns:
<br />-l
<br />trrc ud will roinr n a CcnificBre of ConFnr ro Scli lnsurc for wo,kcN compcn$r i.n. & previdrd for hy s(rn lr700orrhc
<br />Llhor Cqlc. tu th€ Frlbnumc ollhc rclt I(tr vhi.h lhc naln is nsucd.
<br />lh0v.rnd trill'nrinr0in workcra compcnsaiion iNunkc. i\ rcqurcd b, SLrrion.17L0 oflhe Libor Codc.lhr lhc pclfolmncc oi
<br />lhc wort fttrwhi.hlhis p.rnir is issucd My wo.kds comFnsriotr insurancc .trdicr .d Inicy .u rbcr m:
<br />I ccnilytln in rh. pcrfonrnrc ofthc {oll tor whi.h rhis p.flnn i\ nsucd,I shulln.r ctnplo, n"t pcson in ony nunncr
<br />h s r. LronE suhr.l lo rhc wolksi onrl,c.slrion loqs of C.liio,iri0. 0trd rsrcc rhlr if I sholld hcconE suhj$t h rtr
<br />$ortcr( compcns0rion prcvisions olSa'ion 3?0ooflhc titrr Codc- I sh.ll. fonhairh..mtl, with lhoc proltionq..
<br />$.\RNtNC 1'xitLtrd !) \r.urd \o,t.,\ .onrJr.nsrrirr ro\.,rgc ir untNh, xnd $xtl
<br />Y:r'u'rrYw
<br />u\rnJ n,,llrr\ lll(ll).ol)i)r. ir x(ltlir
<br />Lt(I,Nr.ulalt&rrlr2tsl2Il[r$II&N
<br />I hcrhydtllr u trd* r{nrhy ol Friury rhar I a t li$iwl under ptuvnion .f Chprs 9 t.onntN in8
<br />of Ih. Businc\\rDd lhlc\\nnsCodc. ard mylicctr* i\ i', fulltu'cc anJ.ffccr
<br />CONSIRT'(]TIoN I FNDING AGENCV
<br />I hcrchy amrnr undcr Fnlhyofperjury lh.t rh.rc ir ! onrrudhtr lcndirS aSemy lor lfic po{omn.c olrlE sork ror *hi.hrhis F.mir i\
<br />nsucd (Ss. 1097. Civ. C.)
<br />APILICANIDDI;I,TIAIIO!
<br />I hcrb, dnm undcr pcnaky orrc{ury onc ofrhe aouoeii-g dcclmri.isl
<br />Demlition Pcrnik'Asbcstoi Norificarion Fc{cral Rquloriotrs (Tirlc40. Parr6)
<br />-Rcq!ned
<br />Lctrcrof Notil&rion
<br />-l
<br />cdilyrhit $c fcdcrrl rcnrkr nrns reBUdinS artcsos Emovfll 0rc nor 0lplicnhlc rolhillrojccl
<br />_l ccnily rhrr I hrvc rcod rhn lpplicorion and shre rhlr rhc isrccl{icotr]Plr_nirl,rl/CiryaidC.unr,
<br />orJimflccs a ShrcLierrcl iryro huiili
<br />ilxr. nrIirnrd |(iNny|nr
<br />,\pplic"nl or rrtrl Sirnrturr :';kzf,
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltaqe
<br />F ire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondinq i Groundino / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soflit Rouoh
<br />Ceilings (T-Bar RouOh)
<br />lt/leter Release
<br />Rough
<br />Service lvleter ,l
<br />FINAL KI4L lBt w)ffi
<br />Notes, Remarks, Etc.I v
<br />7
<br />Pemite nanr lpnnl):
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