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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE COMMENTS OWNER BUILDER DELCARATION <br />I hdchy rmfln undd p.nrlry oa pdjury rh.l I en .xdrpt aro,n rh. Contcclo* Lic.ns. Las for th. followins r.e. (sE 701 t 1 <br />BBin6s dd Profdsion Cod.): Any Ciry or Counry rvhich r.rlut6 a Fnn ro coGttu t, axd, inprova dsnolish o q€t uy <br />srtucru€, Fdor ro irs isudrq also Equn6 rh. a])plicer lor su.h p.mfi ro liL a sirncd sr0tmdl lhar h€ or shc is licemcd pmoel <br />ro rh. FolisioN of$. Coniraclors Lic.ns.d tlw (ch.pld 9, (omm.ncinE with Serion 7000 of Division I ofrhc B6inds Md <br />Pmf.sions Cod.) orrhol h.or sh. is ci.mpt tho.ftom &d rh. bsis lor th€ aucsed.&n6ion. AnyriolrlionoaS..lionT0ll.5byany <br />aprlicanl ior a p<mit subj..rs rh. applicer |o rcivilpcoahyofn.r rorc rhd fiv. hundr€d dolld (S50o) <br />-1, <br />a o*rdoftheroFry. or ny.nploy6 wi$ *as6 d rhet src coEp{Mion. sill do lhc wolt dd lh€ slrudm n nur <br />inidxlol oi ordcd for slc (sE ?04,1. BBios ed Prcf6sio.s cod. The (onrrucloi s l-ic rc Larv do6 nol apply io m o*.d ol <br />rlE lmn<ly who builds or inpture thsol! rnd who do6 uch q) hn scla or h.&ll or nmxBh his o! hq o*'n cmploy!6. <br />nrovided thd such Lnprovondls e mt inl6d.rl or ofi€Ed for slc I L hoso6. lh. hildins 6r itrrpov.ft is sld Nilhin on€ yw <br />ofcompldio( $e (]1l@ Buildd will hav. th. buLo oaprcvins rhd hr or she did nol build or imFolr lh€ propdy for th. purpo* oa <br />I. 6 .*id oarh. p6pdr, m qclNircl, contrdin8 snn lirms.d conliadoE ro c.nnru.r rh. FoJcr (sd 7044. B6m6 <br />ad Potusion Cod.:'l'he conticior's Li..ns Law do6 noi,pply ro tu owna ofpropdy$ho builds or impror.s rhdsn. <br />and rvho contmds for such Fojccls with a Contraclo{s) lico'$d puBrol lo lhc conlncldis Licmc L.w). <br />I m cxmpt unddsdlion . B & P.C.forlh$ r6on <br />Dot.: Own.r: <br />Ia!5I8LCA!IfENSAIIA! <br />DECI.AMIIAN <br />I hn by alfim undd p.tulry olpojury onc ot th. aollowing d(h@rioN: <br />I hav.tudwill mainlain a C.nificat. of CoIMr ro Self-l.su!. tor wo&ql onrpe.!.lion. s pmvid.d tor b, SEtion 1700 ollhc <br />t bor Coiq aor th. pdforl@.. of lh. {ort aor wnich ih. pdmil b isu.d. <br />I n v. rnd will m.inld. wo*6 compssalion iBuranc.. s r.qun.d by SErion 1700 of lhc tlbor Cod., aor llE pstmcc of <br />lh€ work lor qttn thir pdril b is.d My world conpqslion iEudcc .an6 ad Flic, nnmbd dt: <br />h .4s <br />I. \ \CL <br />-l <br />c.niry ltar in rhc p.rfoM.. oa$. woi{ for *hichrhi3 tdmir ir issueil I shrll nor.mploy ar} pcr$n in my oend <br />$ 6 ro bn{,n subj{r ro rhc sorl6' comFrudion laws of Caliaohio. ed asc thal if I should beom. subler to th. <br />mi(6' codFsrion povisioN of Sation 1?00 ofln€ L.bor Code I slEll. loflhs ilh conply r irh lho* prclGions.. <br />W RNINC: rrilur€ to su. wor(6' coh!.6ation c.vda!. is unl,watrl. md shall subjd an enplolt lo flninal Fnati6 nnd <br />.ivil lin.s up ro on hu.di.d rholsmd dollN (1100.000). in addnion ro thc cosl olcomp.Galion. danagd 6 p.ovid.d ao.lt. <br />Sdion 1076 oluc htn. Cod€, inldd &dotlumy's lG ,2 <br />,,","1{0V | 5 2018 <br />DECI.ASAIIAtr <br />I hscby afinn undd p€nAhy o I p€iury rhal I @ licotsal unds previ.io. of Ch.fl6 9 (commdcinS wnh S6liotr 7000) oa Division .] <br />of fi. aosins &d ProieioN Code. sd my licos. is in tull forcc d cfrat. <br />9 toccn qQtl <br />,,,,, NoV I 5 2lll8 (.*in.,.r (-114,M^ <br />caNsrauqu0lL[NDtNc-&cElljr <br />I hftby aitnn ondd p.nah! ol pdjury ihal liqc is a oNrudion lodins asdcy aor lhe pdtunnec. of ln. wolt for u hich lhis p6nil is <br />issu.d (se.1097. civ c ) <br />ATII.ICANI-IECLAAAIIA! <br />I halq.fuDundd p.nahy ofp<jury on ofrhc tullowins d6lrations <br />Dmoliriod Pmtu Ashdos Notificarion F.d6rl R.SularioB (Tnt 40. Pan6) <br />R.qun.d L.nd of Noi6cdio. <br />l.dily rhar rhc Ld$al rcgulalio.s re8{ding 6b6tos lanor.1trc nol apphable lo Ihis pojel <br />cdilyrhdrhav.r.0dthisapplicarionadsratelhatrhcabowinlomarioo6co'rsrlsrrero.onplyNnh0llCityandCounly <br />ordinancB sd srarc Lrws rclatin8 ro brildiq connrucr .frhis City&d Counlyto t6 upon rhc <br />rtrr. 'nd ur p'oFn\ ntr iNtrtion <br />Irl0v <br />\l't'lirtrtrr or 1[{r Sistrrr rr <br />5q'..a,L A <br />I 5 20t0 <br />Site-Work <br />Underground <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soffit Rouoh <br />Ceilings (T-Bar Rouqh) <br />[\4eter Release <br />Rough <br />Service lrileter <br />FINAL a-/rnM t\tl <br />Notes, Remarks, Etc. <br />ID/SIG. <br />Pole Bases <br />Pnri.yNu.b., @E.pn* <br />T