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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG,, OWNER AUII-DDR DI]LCARATION
<br />I hcrcby trlfiirn uftcr pcnolr, or pcrj!ry rhur I aD.xcnB amn rhc ContrucroF l-icEn* Las ror thc folloRirrs rc,vr rsd Toll5
<br />Busincs lnd Polcsion Cod.): Any c y or County {hich rcquirs s Fmit ro sn{rucr. alls. improrc. dDmlhh o, rcprir rnv
<br />{d.rn6, Eior r. hs is$dRc. also rcqutcsthcat icanr ,or slch Fnnir ro fika siSned slatcmnl rh ltor sh. h liccnscd Pusuonl
<br />ro rh. rmvhions of rlE Conr,!.ror'r l-i..n$d I:w (ch,ptcr 9, Connmrcin3 wilh s.c'ion 7fix) ot Divnhn ] ofrhe Burin.$ and
<br />Ptufcrsn,niC.dc)orrhnth.orshcncxcarprlh€rcnoflr!drhch€sirforrh.dlcgcdcxcnrbn.Anyvn,hrionofSccrionT0Sl.56yany
<br />.rpphc.trrlor!tqrnir.ubJsr.rh.rnr'(,nr,.aci!,lNnrlry^fnormrcrhnni!.hund',nd.llI\r(\tro,
<br />'\Y."*,"r,r,"r,.r.nr.nrmy.nFhJ.cswrhsa8c.rslh.r$horFnuFn.wrlld.trrqurtrdrhc{ btrmr
<br />i'rrcdcd or ollcrod ror slc (S(.?o44. Busircss and ftofcssioni C.'dc: Thc Conract(tr s Lien* L€e do.s norlltl,lo !tr osM ol
<br />Ihc ImIEny whot lds or in{m,ks rhcdr. drd *to do$ su.h tro himscllorhcsclforrhmushiisorhcrow!cmpbvccs.
<br />niovidcd rhar su.h imnn,rcmnk rc fr,r inr{nldl or ofi.rud for suL ll h.wctcr. lhc hilding or inptrlrrcnl is siil sirhin om Fd
<br />orcomnkrbn. rh. OwNr Buildcr willharc thc ttrdcn olF,vins rhd hcor shc dil mt huild oi imProw rhc pFFnt ror thc l,Uqncof
<br />I. d\ uwrcr of thc noncdy- omcxclusivclycontacrn's wirh li(n*d .utrkr.lo$ i,' connrud rhc Proj.u lS.. TOr'1.llunnc$
<br />d Ptr,fs\hn Codc Th.Codtr.roas Li.cnsc Law docs nor anplyn, anown.r ollr.tcrly*ho huildsor ihtrcvrs rhcrcotr.
<br />nnd who conrB.* lor ru.i projcclr qnh a G, m.bn n li.dtrtd pur$rnl h ric Conrrackn s Li..nsc b* )
<br />I hcrchy rl nn u d.r Ntulry olpcrjrtry.nc of rhc lotr ine &.
<br />-l
<br />iovc ad will msintanr n cd in.nrc ofconscnt ro Sclf.lnsurc lor sork. .otrrpctrcdion. is Provided fo. hysc.ri.n l7m orihc
<br />trbor Codc. for lhc I,crforromc or rh. wolk ror whi.h rh. Pc.nir n irsucd
<br />-l
<br />hatt nnd will dainhin sortcB compcnsalion nsurancc. as Ntlircd hys(rio lT0O oithc Llbot Codc. f.r rh. Pc.rornundcof
<br />rhc sork tor whi.h rhis rfimit is tsucd Myvorkcr' corpcnslrtrn in rtrnlr.inicr d policy numbct uc:
<br />A[q:*,,,," ",* ",",,,,...,,,,n" ",,,.;I \lrllno' cmploy trtry pcrson intrn, Ba.n$
<br />rcc rhor ii I sbuld lrco,E suhlccl to lhc
<br />flhwiin onv,l, sirh rh)$ ,)rovisions
<br />\i rs k, t.uo'D $hjtcr h rhc ! orkcr compcnsrri(in hs\ ol Calinniir. t t +
<br />trorkc^ .o rFnldl.n pnrvfion\ oiS.dbn.l7(X) frltLrhnCl r.Ishnll n
<br />$ RNIN(I F.ilurc ro ecurc *orkrrr .orpcil rion.o!c n8c n un[srul. rnd \hxll sohjc.r m ctrploycr lo
<br />, nr addirio. ro rhc .oi oa.oBp.6sdn{, da.nAc.ivil lincs up to onc hundrcd rho!$nd do
<br />:,""":''CI1Tb1'@
<br />'l Lb<,""J-I hcrcbytrnnnundcr pcnalryorp.rjuryrhnr l,'n li..nsd u h Sdrin, T(Xn, ofDivirirr l
<br />of rhc Busine$ and Profesions Codc. aJ ny tic.nrc in ruu loie arxlcflccr
<br />CANSIAIIJ:IQNIE DING.AGENqI
<br />I h.Eby aftrm undfi Fnrxy of pciury lhal lh6c is a mn(odbn lcndi.S aecncy for the I].rfottuN or rhe rcrk for *hici rhi\ Itmi n
<br />hsucd ( sa. 1097. civ c ).
<br />AfIIIIANLDECLAXAITON
<br />I M,! olftrm undcr pcnallynfpedur, onc orrh. rolldwing dc.ltrorions:
<br />Demli'io. Pcrmirs Asbcsos Nolificllion F-cdcrol Rcsrlolions ('Iirl..,l0. Parl6)
<br />RcqunrJ Lc(cr.f Norli.dion
<br />[#.;
<br />ilyrhd lh.ltdcrrlrcgulaltnN toEturiins r\bc{os onovalrrc nolqrPli.rhl.io rhis Pojc.l
<br />rhor I havc rcad rhn ApI.arbn nnd starc th0l rhc utivc infodarion i\ coftcr. I a3rc rocom!
<br />nd Srlrc tf$ rcL'ing lo building conslruclion. ffxl hcrcl,y au
<br />dlnvc rxtrli.ncd prepcny ftn inspccri(,nll 'Alo,ru
<br />ADpliunl or Alrnt Si[n lu M-a* Utr
<br />ly*irh rll Ciryand Coxnr!
<br />ry rnd Coutrty lo cntcr uF,n rhc
<br />:"lLills
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Liqht Slandards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER
<br />Transformers
<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 & Soffit Rouoh
<br />Ceilinos (T-Bar Rouoh)
<br />Meler Release
<br />Rouoh
<br />Service Meter I .A
<br />FINAL \-\t \R nftfl 4,-,
<br />Notes, Remarks, Etc
<br />COMMENTS
<br />" x-,2 -
<br />reW
<br />tJndd ' Nnnr.
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<br />trnd.r t Addrc$:
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