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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDER DELCARAllON
<br />I hcrchy aflnn undcocn,h, of !,crjury lhar I am crcmpr lKm lhc conlmdoB Lrcns L.w r'or thc lhllowiq rca$n (Sc.7o.ll 5
<br />Bu\incss and Profession Codel Any Ciry or Colnly which .cquircs a Fmir Io con(rucr, llrcr. improk, dcnoli\h .r rFi ,ny
<br />(rucru. prnn b irs nsuancc, als aquncs th. 0pplhadr ror ru.h Frnit ro Llc r siSncd {nrcnrd rhdt hc or shc is li.cnsd pusuonl
<br />ro lhe !tuvisio* ofrh. Conri.r.ls Liccnscd |lw (Chapicr 9. ConnEn.in8 sirh Sc.ii.i ?fl of Oivision:l ofrir ausincsr and
<br />ProfcsionsCodc)orth.l h.or shc ncxcmpl lhcrciro,nand rhctusis l(tr rhc0lkFcd.xcn{rion. nyviol ionol'Sarion70.ll5 hy any
<br />rprlicanr tq o p.rnir sul'jcch lhc arplicanr ro acivilp€n.lryofnor mrcth,n live hundBl dollss ( $500)
<br />l. {s owncr oflhc poFdy. or my.nrploy(s wnh w,gcs r\ rh.ir y,lc.rmp.trutun, wiu do lh. wtrk rnil thc $ul& is rol
<br />i cndcn oi ofcrcd for slc (S( ?O44. Busirc$,nd Pmltsions codc Thc Conlnclois Li.ensc tiw does n l aml, ro an osNrol
<br />rhctmr.ny sho huildi or inlrmvs rh.mn, dd who ddr tuch knt himsclfo' hc'tulfor rhdlgh his or h& o*n.nrtlor.cs.
<br />pn,lided rhar such impDvcmnh e mr inl.rdcd n oftcEd for srh ll houcvci rh. hoildint or inrowrmnr is wH wirhir nnc jtr
<br />olcon{'klion. rn€ Ow.cr Bui}:Li will hrvc lh. bunlcnolpmvir8 rh t or shc did Rn hoill or inoorc thc potLny i.r lhe purFxc of
<br />I. as owtrr .f rlt. fn,pdt, 3m .xclusiv.ly .onkrcr in8 wir h limn{d conrrr&tr\ t, ..n{rud lll. ptuj.{r (Se 7(ll-r, Bunrcs{
<br />ml Pmli:siotr Codc: Thc Cotrriodor's Li.ctrsc Lrw docs nor onrly ro 0n oqncr otp.opc.ty who builds or in]lnovc\ lfi..con.
<br />&d *ho onrEckforsuchltr.jcclswirh!Conrrlctorls)liccnsnpuisurnrrorhcConrracroisl,icenrlnw)
<br />I sm.rcnrDr undcrScrion
<br />uaBrEf,lroutllsAlllr!
<br />DDCI/AAIIO!
<br />I hcrcht rfinn utrdcr pcn&hrolpcrrtrD. onc oflhc n,ln,$in8 dcclo,llions:
<br />-l
<br />hlvc 0.dsillnEinhin aCcrliricalcofConsent lo Sclf.lnsurc ror wor icr' comp.trsri.n. as lirovid.drbrbysccrion:lTlx,oirhe
<br />Lahor Codc, for rhc pshflMkc ol rhc worl for which rhc !.i!nir ( ksu.d.
<br />Nl!mpciun n,\m .c.rrit
<br />OJL
<br />vvco
<br />-lccnilylhar
<br />inrh€ ncnblunccollnu *ork lnr *hich lhis pcnnil i\ h$cd.l shrllnor $rdoyiny |r!(on iranyalnncr
<br />\o asn) tno f, subjcd n,rhc workds..'npcnqrn,n h*roicalii(mi!. md rsrcdh irl shduld h.c.N suhid nr lhc
<br />w.rkcrs cotr,Fosari{nr pmvi{bns ofS.crbn l7O0olrh. Lllxtr C(xic.lshlll tunhsirhcomply {nh rh,r pr,li\nnr
<br />l4ARNlNc Fnilurc l() *.uto wo&cr( co pcn\arbd cnrersc i\ onlswrul, Md shnu \uhJccr dn cndoycr ro dnnirl ncmllics ud
<br />civil 6ncs ut lo onc hundrcd rhousnM dollars ($100.000). in rddirnri h rhc.o( or confc.sariotr, dlnu8cs as providcd fu lhc
<br />S6.-rion 107(, oflM Lrhor Codc, i .rcn!M nr*y sfN\
<br />4,L.lc.
<br />DECI.AEA.IION
<br />I h..b, amrhrnd.r pemlrrotprrjury rhar I am li.cnsd lnd€r prcvnnn ol Cluprs 9(con,mNins wirh Serirn 70s)) orDivhnJn 1
<br />of rh. Busircs and Pmtcssions Codc- !d my liccn* h in tull lnra exl clfcct.
<br />6 lOeat<'t-
<br />a.G.4 -hrra
<br />rat aucraNuiNDtxli-aclNqr
<br />i\\ucdrsm :llD7 Civ C )
<br />L{nders AddE$:
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<br />-l
<br />ccrlify lhd lh. tadcnl lc8ll iotrr E8ardinB a{$los rcnwal m mt 0pplic,bk r. rhis lmicl.
<br />4.:5lny t.ut I lirc.can $i\ lppliclrion &d srarc rhd rhe ft've inromt nn ir corcd I asd t. c.mply wirh rrl c'ly and counry
<br />ordinric.\ rdJ Srxr. lr'$s rclJri',9 h huilding rulhorncr.lnc\cnLrnrsol rh]\CiryrDd(.unr!r,r rrtrFr f,
<br />xhovc rnri,nrd nrotcny f(tr i'r\tB.^^ri{'n
<br />ADpli.n.l.r A,tenl Si*nrlum
<br />-h aal r/ 4,,
<br />4-CtaDsr€' f, a.
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Salety /Low Voltage
<br />Fire Alarm i Dam pers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER
<br />Translormers
<br />Torquerng
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Facto ry Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soflit Rouoh
<br />C eilings (T-Bar Rough)
<br />Meter Release
<br />Rou gh
<br />Service lVleter
<br />FINAL lr q ttJ%
<br />Notes, Remarks, Etc.
<br />l.L lc1
<br />AIELIIANLII&CI.AAAIIIJN
<br />I h.mby rllro u ndcr lcn,lry ofl).rjuryonc.rrhc fouowiig dccl&tn,Ds:
<br />D. xnirion Pcrhih Ashenos Mriicdrioo rcdcalRquldions (Tillc 40, Pan6)
<br />_Rcqutcd trtcr of N6rifi crrhi
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