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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUII-DER DELCARATION
<br />I h.r.h, dltnn tnder Fialty of F jury rhll I m cxcnlpl rhn, thc Conlmdos Lhcnse Liw lnr lhc follo*iry rce$n (Sc. ?03 1 s
<br />Bnsincss .ft1 P!.f.s\ion Codc)r Any Ciry or Cornry which rcqribs s lErnir h conntu.r, !lrs, inFn,vc, d.mlish nr ml,air sny
<br />struclurc. trhr ro ils ksuonce.oho rcquncs lhc amlicutrr tar su.h lcanr ro tilc 0 siSncd slslcirc thol tEor snc n licctrsd purunl
<br />ro rhc pmvsioN ol$. Conhcrofs Li.cnscd tlw (Chryr.r 9. Codncftine wirh Sc.rion 70o(r of Divi\io.:l olrhc Busin.*..d
<br />Pmicsions Codc) or rhal hc or she h cxcmpl thc.cliomand lhc bash lor lhc 0llcgcd cxcmption. An, vn,klion .l Ssrbn ?031.5 hy any
<br />.prlicah! iaru p.mir sul'jcch rhc arnli.a ro !civilpcnllryofror mlc rhln filc hunded doll&\ (StoO)
<br />l. .s ovncr of rhc t oFny. or nry cnrlloyr.s eirh wrsds ,\ rhci, $h snrpcnsriotr, sill d. (lr sort aM rhc srrElm is mr
<br />inlcndcd or oftrcd for slc (Ss.7044. Busincss nnd ltorcsbns Codc Thc Contacroi s Li.cns L.s docs nor omly ro !n o*ncr of
<br />rhc pbp.ny who build\ or i'ntiok\ rhcto$( md whr docr $ch s* hims.ltor hcrcltor rhrersh th or hcr own chpbrcfr.
<br />pmv Li rhdr sEh impoErEtrh N dn imelldql o. ofic6J f.r srlr li hwcKr. rhc hoikiin8 or hpovcm is $b wirhin oft ,.r
<br />oion{Lion. rh. Owrcr Suildcr will h.w rhc hrrdcn of8)virg rhd lEor\hc did mr hoikl.r inpr.vc rhc pnrFn, fi, thi |)U4r$.f
<br />1,,!o*ncroirheprcp.dy. un ciclu\ivcly conlructiry wirh liccnrd conlru.ton lo conslruct ttE Dmjccr iscc 7044- Bu,nc$
<br />and Pioissinr Cod.: Th. C.nkrrofs Lic.nsc Ldw doc\ nor ltrly k, mownci ufpropc(y shD build\ nr inpi.v.s rh.rcon.
<br />and who conalcr\ ior $ch poJcch oirh a Conhcrod, liccn$d pusurtrr ro rh. Conrr!.rols l,iccnr Law).
<br />I Dcrr.rpi tr rlcrs&ri0n_. B &PC lirrrhi\r.rvrn
<br />Drl. Ou..r__woRKxffi
<br />PECLA8AIIO!
<br />I hercl'y atrtrm und.r p.nally of Isiury orc ord. lonowh8 del@rio.s:
<br />-l
<br />hlw oid sill @iniain a Cdiar.r. ol Con*m r. Sclf lBurc fo wor*6 snp.nsalion. m pmvilcd lor by S(lion l7m of Ih.
<br />ht$r C.d.. t6r rhc pdrornance of rhc work for whi.h lhc loni n nslcd.
<br />_l tovc otrd will minlain wortcB comp.n$lion insurarcc, rs FquiEd by Serion l70o oflhc L3bor C.dc, for the pdlolr:lmc of
<br />lhc wolk tbr whi.h lnls Fmit is hecd. My worl6 omp.ns.laof, instrece .fiid .rn loli.y numh.r m:
<br />c*",, 3a te fi,,vr d
<br />(-)58 5t/bl5
<br />-l
<br />ccniry rh,r in rh. pcrlortun.c ofrhc work ntr whi.n fin pcrmir is issucd. I snallnor cmploy lnyFson io an, nunifi
<br />e rs lo bccom subjcd to rhc worlc* comFtrs,iion hws olCrlilorni,, nnrl aercc th,t ill should h.com subjNl lo ttE
<br />wo(cr{ .on9cnsdion ,Dvisions oi Sccrio. l70o of $. hlr, c'odc, I \hnll. lonhwith .omply wir h
<br />'hos
<br />pmrnn,ns.
<br />$ARNINC Friluc b $ur. rvorkc^ $alr.tr\ t,n $\! gc i\ unh*111. rnd \1 11{rt,tcr a',.ndovcr n) ci'ninall{mhi\ ril
<br />Sc.rtun:1076ofrhc ljhn C.d., imcic{ ntrildrflry \ f.c\
<br />AJl,cL
<br />I hcBb, of,ifln undcr pcn.llyofrcrjury lhll I a'n lien{d uklcr Fmvnio. otChlrls 9(commrcin8 uilh S€lion 7000) ofDivi\ion I
<br />of rhu Businc$ dd Pi.fcsions Codc. dd nrt li.c6sc is inn rr.r! iftrrrilI
<br />tDt-713 6
<br />D,," 1t25 / I t, c".,,"","",t"7t
<br />CANEIAICIIONIENDINOA(iENCI
<br />I icEby aifirm und.r lEnally oI ,Errury lh.l llm h a mnslEcri.n lcndinB ascmy for lnc pcrfotutuc of Ihe woA ror which rhir Fmil h
<br />issu.d (sN.1097, civ. c)
<br />dITLICANLDECLABAIIO!
<br />I nnby anim u.df p.n.h y of p.rjury om of fic followiog dcclelions:
<br />Dcnrniion Pcrmih Asbcsros Norilicnrtuo Fedcral Rcguh bns ( Iirlc 40, Pan6)
<br />Rcquted l.trc. ol Nnir,catkrn
<br />I cdity rhar rh. tddcrul eguldions ogditrg asb.{os r.mul rc .or al,plic$L b lhn potcl.
<br />ljl cdrry rhd I h,r rctrd rhr rrnlrrrrnalld nlrc rhor Lhc 0lx,vc innrnurbtr h corccl.l Isr ro conrply virt allCny lnd Counry
<br />ordinances md Srire Laws Ehtitr8 ro buildin8 constru.rjln. and hercby !urhon7. rct rcscnrarirs oirhh Cny and Cou.rytd.nro !F. rhe
<br />rhovc mnlioftd i,mpny ror inslEcrio4IuF6!.
<br />noor,** * nu^rru*r,r41?r44 1:144L l
<br />Prm,i,rt ndn. iprinr,: 1*, t kll:,ll o
<br />7lz5
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool, Founlains
<br />Signs (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communrcations Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Translormers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />Meter Release
<br />Rough fil$((6 :N6{
<br />Service Meter
<br />FINAL \ /t{/7 5D6b
<br />Notes, Remarks, Etc
<br />Pole Bases
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