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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUTLDER DELCARITION
<br />I hcrch, affim undcr ,,cnahy of prrjury rh l am cxcmor fmnr lhc C.nracNr Ltcnse Lnw lnr rhc iollowin8 rco$n (Scc 70rl 5
<br />Butin.ss rnd Pn ir\i.n Gdc) Any Ciry or Counr, *hi(h rcquircs ! pcrnrir b con(dcr. alrcr. impro!.. dcmlish or Erair any
<br />\lrucrurc, I,ior to irs issuanc., al\o rcqutN ihc dppli.rnr lo! ru.h pemir t, filc r \ig@d {r cnrnr rhd tr.rshc i\ li.dnsd pu^uanr
<br />ro rhc piolniotrs oflhe Conlachr\ l-ienscd Lap (Chiplcr 9. Co,nnrcn.in8 *ith Scclion 7u)0 ol'Oivision 3 .l lhc Busincss and
<br />Pnncsn)ns Codc) or rhar h. or {h. i\.irdpr rh.tcr.om lnd rh. bush lor ric allqcd crcmprion. Ao, violarionofSccri,n?O.ll5 by any
<br />ifpli.lnl for a p.nnit subj(* rh. rmli.a.r ro.ci!ilp.nrlryofhor mrcrhrn livc hunddddollr^ ls5m).
<br />l. osicrofihcI,(,rEnt.ornrycnrrl{,rlcsqnhr,scs!slheirrlcconrpcn\llion-willd,rh!w{trk! llhc(n{1urcnior
<br />i .frLtl or oifcrcd lar \rlc (SL! 7044. au\in6s and Pnncsion\ cldc: Thc C,,ntncktr s Lic.nsc I]w docs ndr amly ro ri ownfor
<br />rhcnn,Iicny wlx' hu ilds or inqovc\ rhcNtr,. ud who dms such qr* hinNcli or lErscliorrha)ugihis or hcr own cmployc.s.
<br />prolidcd rhlr such nrmtcmnh,r mr ruxhd d oicrLt !(tr sk ll h.q$tr. rlr b{ilding or nnoturnrnr n $h *irh ''ncFrrof.onlrLrkr. rh( Oancr Buil&i *ill hr\r rh. htrdcn oftn'lin8 rh3r hc o. \hc dA d hitl or inrprow rhc p6Fiy fff rh. lxrF,r of
<br />l. N.strcr.trhcrn,pcd!. rtrrcx.lusilcty.o.tr.ri'rg *irh licsdtcd cDfuictn k, ..niru.r rh.!n,ld.r(SLr 7(N.1, Bustrcss
<br />n l l\.ltsb.CoJc'lhcConhcnnsl,iccnscL!*docsmrnpllylornowncrolpropcnysh.buildsorimprovcsrhcrcon.
<br />!!d *ho .onrd.hlor such rn,jcch with r CDntrft,n, li..n{d nui(urtrr turhcC.fiacttr-s Li.ctr$ tiw)
<br />-l
<br />m cxcmpl u.dcr Salio.-. 3 & P C for ihis rclwn.
<br />D,lc OPner:
<br />WORKFRS' CoDIPTnL(iATI(rlt
<br />DECLIXA.UAN
<br />I hcrchy aratr undcr p.Mlryotp.qury.n. ofrhc rouowin! deldationi:
<br />lhr\. xlvill'tuinrri', rCcnifiurcolCon\ctrrt'S.lt:nsurc I(, workc^ llnnlxtrurnrn. n\ pn,eidd for6ySdrnr.lTtX)ofrh.
<br />l,JtxtrCodc.tnrlhcplrrirrnrnceofrtu*ortlhrwhichlhcn!.nir isissu.d
<br />Ihdvcridwill rn ni'r wor*ds .o Nns ri.n nnurui.c, r\ r.quncd hy Srcr iOn l?(x) oi rhc Inhor A)dc. for ihc po linnnmc ol
<br />rhc qork tur qhi.h rlri\ r.n il is i$n.d Myworkcs coitp.nsrrbn nNuhncc.!fti.r drl fx)li.y nunrb.r dc
<br />c,,,i". \nt ll,l.,{) C-kS. ,tE -
<br />I' t. \r.o
<br />-l
<br />ccnifyrh ir lhc |xrlhrnntre.,lhc *ork iu *hichrhi{ pcnir n i\\ucn.l \hallnor cmpl,iy rny lcrv,n in 3nynrrnner
<br />n,r\k,brrotrr\uhJccrk'rhcslrkcricomp.r\rn,nh!\ofcrlinmia,r tl8R. rhd,fI \h,ukl h{ r \ubic.r hrhr
<br />workcd unl!.n\rrnrnpRrvnhi\ofsrcri{ul7(x)ofrhr l]htrc{x!e_ I \hxll. n,nh(irh.o'npll \irhrtk){ ptuvAiotr\
<br />WARNIN(i FJilurc [) rcurc trork.ra.on,Fnsrri,r.o\cruEc i\ utrh{ln]. xnd \hrll \trhpcr , rffk)yrr trr cin rrl F'rlra\ ind
<br />,JuL 182018
<br />!2rgJutlu0ti
<br />I hcruhy rftlr rund$ pcialryoflr!trry rhtrr I n li.ci{rl otrdr Eovnio olChrttcr9(..'ntr*NitrBwirhSccrn,n?000)olDivisionl
<br />of rhc Rusincs d It r'csionscodr, rd mylicctr\c i\ in iulliorcc and cllicr
<br />(1 \tpq?c.t
<br />*", luuL-l G Illlu ...,**
<br />IIIN.IIBUqE)NIENDINCICENJ]
<br />I heruby aotm undd Fnahy of t rlury lhal lh.rc is . on$rucliofl lcnditrB a8crcy lor lnc p.rfolmrcc o, thc *o,t tor whth rhn Fmn i\
<br />nslcd (S...:1097, Civ C )
<br />AfILISANLDECLAMIIO!
<br />I hc,r6y ,nim under pcnrhy .r pcrjuy om .l ih. r.lloe ing deldarions:
<br />Dcmolirio. Pcrnrirs Artrsros Norifi.arion Fcderal Rc3!lariotrs (Tirlc40. Parr6)
<br />_Rcquird L.nc. o{ NorifEarion
<br />$ovc
<br />'Bnlioncd fh|Eny lor inspccliotr l,urB)scs.
<br />Appli.uni or Aaot SiIDlrr€.b.1,,.:J 2O1E
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<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 Rouoh)
<br />lt/eter Release
<br />Rough 11'lzt/t tDkg
<br />Service Meter
<br />FINAL ga/t7 )L6s
<br />Notes Remarks, Etc.
<br />Pole Bases
<br />?44''/tv't
<br />I..difyrhm rhc fedurDl rcellarions rcBrdine ash.$os (turlal . mt arplicablc to rhis tmlcci
<br />9;n ri ,nu, , **" *oU , nO sppliclrion aftl srsrc rhar rhc nh)rc itrtbnNrion N coftcr I alre ro ompr, *irh alr c t rnd couory
<br />odinancc\ and Stlte L.ws rchrin3 ro blildin8 constEctiotr, ud hcehy rurhoria rcprcscnratives ofrhn Cny and Couryr. cr'q ultn th.
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