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ELECTRICAL.INSPECTOH RECORD <br />APPROVALS ID/SIG.COMMENTS OWNER BUII-DER DXLCARATION <br />I hcrcby ar6rm undcrychohy of pcdury th.' I irn cxcnrl lmm <br />'he <br />C.ntEroN l-ic.n* ljw fot rh. {.lkrwine rcab (scc.70rl.5 <br />Busi.es dd Prolcsibn Codc)r Any Cny or Cox.ry which rcquirc\ 0 Frmir ro onsrud. lltcr, improvc. dcnxnirh or rcFt Iny <br />slrucrlrc. prior lo its issunrcc. olb rcqlircs |fi. aryliitrr for suchlcrmilx, filc! sisned {s(.mnr rhar h.orsh. n liccnscd aursu.nr <br />b rhc [dvniois ofrhc Co.(rcroas l-iftns.d tiw (Ch,nr.r 9. Conrmn.inS wilh Scclion 7Ou) of Division.] oarh. Brsinc$ ind <br />Prord\\i.ns Codc) or rhar h.orrhc i! cxcnpl lhcrclion,nd <br />'h. <br />h*n for lhc trllcB(n cxcmtlion. Anyliohrionolsccrion Toll5hynny <br />nptlic0nt ror a pcnnl subjNls lhc 0ppliclnt to !ciilr.mhyolnol nnrclhrn rivc hlndrcd dollaF ( $5fi)). <br />_1,!sowtrc!olrhcpropcny,(nalycnlPk,ytussirhwr!c\asrhcny,h.orfnsnrio..willdorhcsork{xllhc(rudmi\ndr <br />inrc,kL{ or.flarcd lor $lc (Sr.^ 704,1. Busincs and PmfcsiursCod. l h. Coffacrois I -iccnrc lrw do.r mr ,frjrly ro {n owncr .l <br />rh.fmn ny who buildror i,rryi)vc. rhc' Nn. md who d€s such wnl hiNcllor hcFclforrhrcu8hhisorhcrowncmpt,yccs. <br />proridcd rhrr such nn d$.nNrc n i,ncid.d or oficrcil i(n slc ll, lkrscv$. rl.tr hr rklma or imp(*lnEnr i! $kl wirhin,,nc )rJr <br />ofcotrrilclion- llEOwtrcr Buikls willhlE rhc h{dcn ol prcvins ltu tu or \hc dil n.r huiu or nnpmrc rhc l)lntEny lor rhc puqtrsc oI <br />-1. <br />as o*rc!ofthc lnorny. rnrcrclunllyconracrins wirh liccn\cd conrrado^ k,..ni c h. l(il..! (scc.7044,Iiu{nc$ <br />a.d t\i,r6ri,n Codc lhcCo ta.r.r'sLi..nscllwd..snoranrlyrodnowncrofpropcnyshohuildsori"rprovcsrhcr.on. <br />rtrd *ho ommds ror such pnjcls *irh ! Conr6.rons) liccnscd l,ucu.nr ro rh. ConrEctn \ Liccn{ tru) <br />;lfTdi?H-;;*W.,, <br />DDILIAAII)N <br />I hcrcby.llirnrundcr pcnrlly ol'Frjury onc oilhc rbllo*irr declnrrli,,tr: <br />I harr 0nd willm0int0in iCcrtific{lcofConsctrtlo Sclf.lnnrc f(r wor ter' comp€nsrn,n. !s F,vidcd fuhysNlion ]70ooflhc <br />ljh, Cod.. for rhc pcrfonnrn.c ofth. *ork for shth thc p.rnrl is h\ucd <br />-l <br />havc and will maintanr worlcn compens ion insurarcc. rs !.qutcd h! sccrion l70o ofrht hh.t cod.,lM lhc prrformn.e {f <br />rhc *ork lorwhichlhh nermir is iskd Myso.kcri onrpcnsrri,,n i'rurrrcc.,tridr rd0oltry nun*{!rc: <br />Iccifyrhrrinrhcicrfonutrccofrhcworklarslrichrhisp.rnririshrucd.Isnallmlcnrployrnypcsonntdti1rtrcr <br />$ Nro bccom {hjcd b <br />'hc <br />rortcr compctrsatiotr la's olC.lilonri( tr.d lgtoc rhrr ir I should hc..'m srbhcl ro lhc <br />w.rkcr' .oorix.stri l'mvi\ions oiScclion lT0Oollhc LlEn Crnlc.l\h,ll. ft,nhwirh comrly wirh rlm* lrovisions <br />WARNINC: F,ilurc k, $rtrrc *ork.r'.orn ns i.n drvcfllc i( uDhslul. ind shrll suhicr ,n clnlhrs ro di inrl lEnnlrics Md <br />civil lincs up ro otu hundEd rnou\0nd dollaK ($ll[.UX])dddni.n b rhc c.( ofcon,I.n\rrnni r rFc\ ds l,rovidcd lor rhc <br />:,: '1l,hc Lrhr Codc. inrcrc(anddlorrcy r lccs <br />hlre <br />.DECI,ANADON <br />t hercb, aifirmundcr pcnulrrofpcrjuy rhar I an licn*rl und.r troli{hn orchrptcr I (comnENin! wirh SNrir,.7(xx)) orDrision ] <br />of thc Busimsatrd Prcrc$n,ns Codc.ond nrr licene is in rullaorcc udcfi.cr. <br />IaNSIBIT.IIIANIENDINC.{AEICI <br />I h.Eby {ifirmund.r p..rlry olpcrjury rh tlm i. s conslrucl ion hnding escm} f.r ltc ncrfomtu. or rh. work aor which lhis Ismit h <br />i$ucd lScc.llr7, Civ. C.) <br />AIILII;ANLIIECLIAAUON <br />lfu.rhy.mmundcr pcnally ofp.rjlry one otrhd rolb*in8 dcclarrri.i(i <br />DcnFlnio. Pcirnirs.Ash.sios Noriliclrion F€derrlRceullrionr(!irlc 40. Pd6) <br />-Rcquncd <br />Lclrs.t N.rili.rri.n <br />I ccniryrh rhc rrdcrdl rc(ul.riotrs rc8lrdin8 osbcsto\ rcmvrl { c nolippli.al,L r. rhn p j.cr <br />I ccnilyrhar lhavc rcd rhtopplicarioni.d(ardhir rhcatovc ini,xn i{nr iscolftr ld$ctro..nrlywilh{llCny ndCounry <br />odimn.cs.trd SlDrc hws rclnlfu ro buildinB rucrion,0d hcrlhy turhrnc 'cprcrnralivcs oflhn Ciryand Counrylo cnrer os,n lhc <br />rh,v. Df,drnn'.. pm|rnylar i'trfc.ridr fu' <br />"","7/br(t{,\pplirn l dr,\ur t Silnnlurr <br />I'rrnrilec n.me (printr: <br />Site-Work <br />Underqround <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bonding / Groundinq i UFER <br />Torqueino <br />Sub-Panels <br />Air Conditioners <br />Rool Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilings (Hard & Soffit Rouoh <br />Ceilings (T-Bar Rouoh) <br />Ivleter Release <br />Rough <br />Service lt/eler <br />FINAL tpl4lR 1 dzz) <br />Notes, Remarks, Etc.-l crl : <br />DATE <br />Translormers <br />.ncnrc Numtrr <br />- <br />tt