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I
<br />ELECTRICAL-INSPECTOR RECORD
<br />COMMENTSAPPROVALSDATEID/SIG.
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab i Floor
<br />Bondinq / Groundino / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soffit Rouqh
<br />Ceilinqs (T-Bar Rouoh)
<br />Itrleler Release
<br />Rough
<br />Service Meter tl J>7FINALE tt6il*,I vl,XTtr)
<br />Notes, Remarks, Etc I l-)
<br />OWNf, R BUTLDER DELCAR-ATION
<br />I hcrcby !flirn u.d.r FMxy of pcrjury lhal t dn cicm|n tmm th. ConlEctoF Liei$ bw tot lh. lollowitrE rcasn lsccJo]15
<br />B!{nr$ {lxl Prolcssion CL{c) Any Cn, or Counry whkh rcquncs a lErnril ro con(ru.r, alt.r, imProvc, dcmlish or qEn ,ny
<br />{rucrm, l,ntr ro ils i$uancc, uls tqlits ihc tmli.anl tor slch Frnir ro filc ! sisn.d {arcm rhar hc or shl is li..n\cn Nrq;nr
<br />ro rhc polnionr of itr Conkrrors t.ic.nsd ti* (Chaprcr 9. com,ftncin8 wilh Sccrion ?fi)o ol Division :l ot rh. Bu\i'r$ d
<br />Pn,rc$nnrs Codc) or lhol hc or shc is cicnfl rh&crm'n and rhc bosh lor lhc allcgcd cxcnPlion. Any viobri,nofs.crioh703l.5 h, onJ
<br />lmlicur to, ! pennii snbjck rhc aptlicont lo a ciril penolr, or nor m€ lhsn livc hundrcd dollff {$5m)
<br />-1.!soqNroilhcpmpcny.ormy.mlloteswilhwtr-lcsrslhctqn.onl.n$rnnr.*illd.ihcw.r*ddrhcnutmismrinrcndcrl o, oilcrcd for elc (Sr 7l)4,1, Busircss lnd ftofc$ions CdL fic Cotrmct, s Li*nsc L.w docs nor alPlv b 0tr owrc.ol
<br />rhc FmFny *h.lDild\ o. intmts rh.d,n, arxl wln, dm\ so.h {tl* hiNsclfor herclfor rhrough hh or hc, oqi.ntplo}ccl.
<br />proridcd rhar .u.h i,npn,rnrtrls e nor iordldL{ or ofi.rcd ror s.lc li ho,cE rhc h{i nB or ia{mremnl ii s.ld wilhitr .trc tttu
<br />of.o,q'lcrion. lhc Osmr Bnil&r will hrvc lh. burdcn of pmvin8 thor ls or shc did mr hild or impmlt tlE pmFny for rrE PU4ns oi
<br />-1.
<br />!s owncr oi rhc nmp.ny. rfl cxc,N ivcly conrracring *irh liccni{ onr*cttrs lo (nriru.r rhc PmJ$t ( Sec nn 1. 3 'in..\
<br />and ltofs\hnCodc:ThcConlrrktrsLiccns.LiwdocsnoratDlyr,,"ios.roffolcrry*iohliidsornnPmvcsrhcrcon.
<br />0.d sho conhc( ror \u.h rft)Fch w h 0 Conrruct'rln licdtrscd Nrn.rr ro rfic G'lrrd.ttr ( t-i..nsc hs )
<br />-l
<br />lmcxcnpr undcr sdrnr .B & PC. fdrhis rmen
<br />woRKEks' (l()l!lPENslTloN
<br />DECI AR,{TION
<br />I hc.cby rr'Ikflrundcr ri. rliyorFrjury onc ollhc !hln,$i!8 d.chDrions:
<br />I hrvc !ftlwill mainrri.aCcnific0icofConsnl to Scli ln\urc r(r wo,kcF comPcnsurion N PmvidM fot bvS(rion.l7(n.rlhc
<br />bhor Codc. forthepc ormlme.frhc sorl fot ehichlhc non is n\!.d
<br />-lhlrc
<br />rdd *illma r sorkc^ .otrrcnsrr i{r i'i.ura .c. r\ rcqutr d hr_ Sccrion .l7m of rlt Lrhor Cottc tu rlt rcrnn orN. .l
<br />rhc *ork nn whi.hrhi\ Fnnir is issucd. My*ortc^ cohpcisdi,trlirr!trrn c.rricfuxlloli.y Nnrhcr rr:
<br />P.lEy Nurnh$
<br />-
<br />-l
<br />c.dify rhrt in rhc pcrlornErEc oirh. work aoi shi.h rhis lc.nir is i\sucd.I shall ndr cmPloy any tcr$n in rny nrnnct
<br />$ as ro ti.sm rubirr k, rhc work 6 com,rcnsari.n hss ofcalirdnir d osrc lhnr irI sh.uld h..oN suni(l rorrf,
<br />$orter' Nmrrn\ar ion pmvisk,n\ of Sstion 3?OO ot rhc lrx, A)d., I sh{ll. n'n h$irh qntlly wirh ltbs Pmvnioni
<br />lvARNlN(; I;iilurc l. *curc rorkc^' .oqrns{r! ..vcrrsc i\ utrlx*tuI, r drll suh].cr n cnDl()ycr rr dimiMl Ixnrlris x d
<br />c'vrl lnr.r uti nJ oR hundrcd ihou\r d dollr* (ll 0U)). ir JJrlirn,n b rhc co$ ol co'nP.n\rrn,n. rln r+c\ !s PrrvnlcJ hr rhc
<br />snr'nn 1016 nfIh.,:h Codc
<br />"",..C/rr /a
<br />I h.rchy 3rrrnnndcr p.nllry ol lxrjur] ln l Nn li.an\d ir.df l)tuvniotr oI ChsPrcr 9 ilunnrn.i.s *irhSccrion7l$o) o
<br />.l rhc Busirc\sand Pn,rcsn,ns Codc.ond nryliccnr t in tullturQ dldcfl(l
<br />/t8
<br />istrconnrudi.nlctrdin8asc.cyftnrh.r(fornBnccollncworklnrBhichrhhFnlil irI ncreby aifimrndcr Fndilyolr.rjuryrhul I
<br />issucd (Scc 109?. Civ. C )
<br />bnd.is Nomc
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<br />A.PILICANIDIqdA^ITON
<br />I h.n+ry arrb undcr p.nalry ot p.rjury onc of lhc followins dccl$lr it,nsi
<br />Dcnrnion Pcrmii$Ashc(os Norificsri.n F.deral RcSulnrtuns (1 illc 10. Prn6)
<br />R.qun d kl ls of Noliarcarion
<br />-l.enilyrhrrrhc lr cnlr.! ldi.n\ r.g nln! x\hc(o\r.itrrrl,trc n.r xPfli. hlc r) rh^ l)'(,4.r
<br />,Ci**,r,r,, rl" '*r,r,harprid'un n {Jk rh0t ,h. eh"!c 'nnr Er(n h.nn(, I
<br />| "^,**-L*"1,, ilr,{ A{ttn zo
<br />isE ro comply wilh !U Cnya.d Counly:::a1,:
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