|
ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.OWNER AUILDER DELCARATION
<br />I h.i.b, amrft und.r Fndlry oI pcrjnry ihar I d cx.rpr aon rhc ConrricbN Lisn* tiw ror lhc rrnk,winB rcasnilN rL;
<br />Buliness ,nrl Pturu\sion C.de): Any City o. Coxnry *hi.h rrqut$ , Fnnii lo mnsrrud. sh$, i'ryrovc, rhmlCh q rl]€n {(dclurc. l,rin (o irs i.suamc. dso rauircs rhcapplianl lor such Fnnit lo fiL0 sieflcd slalcEnl lhdlhcorshe n liccnrcd I'tNlnr
<br />ro rhc pmvirions or$. Contr.rd 3 Liccns.d lrw (Chrycr 9. Commcmin8 *irh Sccriotr TuxJ of Division I oi rhc Businc$ und
<br />Prcfc$ions Codc)or lhol lE or shc h excryt lhercfrom and lhc hnsis for Ihc dkBcd cxen[lion Anyliolario.orscc]k,n70ll.5by,ny
<br />lpplicanr for r pcmir slhj6ls rhe aFlicanr ro a cieil pen,lry ot nor Bnc rhM fivc hnndftd dollri($500)
<br />-1.
<br />ar ourer of rhc pmpcny- or my cmployccs wirh wlBcs ns rhcn sh o'qEnsar ion. aill d. rr. qdk nll rh. stutE is ml
<br />inrcnddl or off.r.d for slc ( So.Ilr4. Busircss rd Prorcssbnr Codc Th. (trnt0ctols Li.ctrk Law docs trol lplly lo .n ottur oa
<br />rhc rmIrny pho boildr or iqmtq ltEm!.0d wto dcs skh M* himsclror hcrellor rhn,u8h hia or hd o*n .n{loyccs.
<br />providL\d rhar such impmrcmnh N mr inrc*Ld or ofi.nxl tor qlc. ll l$wrcr rtE huildiry or i.rFoEnrnr is sU lirhin on. FU
<br />.f..hdcrir- rhc O*ncr Bnildq wil haw tlE btr&tr 6f pmving rllr lE or shc ilid nor huih or inpmv. Ih. FoIEry for rlE turlh$ of
<br />-1.
<br />asosncrofthc pro!.ny. ancxclusivelyconlrucrinE wi'h liccn\ciconiracknsbcond r! rhc pn,Jccr {scc ro{. BunNss
<br />d{t th,itsi,n Codc: Thc Contnctn \ Liccnsc Lrw doe\ nor apply i(, nho*i.r orpmr.rly Rho buirds or inrplotcr lhcrcon.
<br />rtrd who.ontrrif(trs!.hpmJ.tkwnhaComnrk,(\)li..n{dru6urnrtornc(.ontrucroisLieoscLo$)
<br />I rn,crcrlr u cr S.crn,
<br />()f,k.:
<br />trcatrf8llg}lltEtt llu!
<br />IEILAB^III}N
<br />I hcrchynrfi rf undc. Fndry olpcrjuryoncof rhc folloBins dccltrrrions:
<br />I h0vc uld wrllmirldnrC.nificatcolConsctrrro Sclilnsurc ttr workcr'conrpcnslrion, as prolidcd for by S.drion lT0Oofrhc
<br />bhor Cod., for rhc p.rforM. of thc qolk lo.whichrh. p.nnir n hsucd.
<br />lhrvcrnnwilnriinlains.rkcn..nrpcnsin,ninsurrrcc,!srcquncdhrScciioirTUJofrhrl-.horC()dc.lbtrltcpcrlonnnNol
<br />i\ ns!.d Nlysork.rr c,rpc,\, i,r i'Nrrtuc.rni$ d tx,l(y trtrnrhcr r.
<br />"th J-t r
<br />VuCo 1v)o t .\ i,i-
<br />-l
<br />ccnilylh0l hlhc rcrhflnarccol lhc *ork tu *hthrhh |Ennn is i\\ucd.l sh3ll n.r c 'rl.yniy!crk,' ir rnyn'anDcr
<br />$ s t,IE(nnc shjcd h rhc lorkcis .onlxn\arnnr h*l orcnlirbrni ,.id a8rcc rhnr ifl sh.ukl bccom suhj(r l. rhc
<br />aork..i comlr.isrri{'n pr,li\nrns of Scci ion 17fi} .f rhc bh.r c(rlc, I drll. Lnhwilh comply with thosc nmvnions
<br />WARNINC: FailuE to surc worlcs'conDcnsalion oveEsc ir unh,nrl, lml ihall subjc' {n cmplortr !o aiminslpcMlics anJ
<br />civil fincs up ro orc hundEn thousDd douus ($100,U10). in oddirion ro rh. co ol.omllcnsdrion. dame.s !s providcd for thc
<br />Ssliotr 1076 otlhc L.hor Codc. iorercn and srromy s f*s
<br />Dsler Appliol:
<br />LLCENIED-CONIIAqtr.IA
<br />DAC!AaAII!}!
<br />I hcrcbyafit und., p.ndlry or l).rrwy thor I am li.cnsd und.r Imvkion o, Chaprcr 9(mmmmnrs vi$ Stlhn 7000) orDirision l
<br />oa rfic Busirc$ Md Pmfc$io.s Code. and ny licen* is in fuU fore. and cfi(r.(3.t o o1.t r. 1
<br />or .G . \ou 1.--.F.. ^ '
<br />COXIiIBIJqII()NIENDIIC.trGI;I1;I
<br />I heEby rfilrmundcr pcn.lty ol p.rFry rhsl rhsc h r on(ruclion bndins ds.tuy for rhc tf,yror.rrrcc or th. work ror whichlth pcrmi n
<br />issucd (Scc 109?, Civ C.).
<br />APPT,ICANT DECLAIL{TIoN
<br />lhcrbyafimundf p.nrlry olp.lnry onc oflhc fouowins dcclararions:
<br />Dqnolirion Pcrmirs Asbcsros Mnifi.arnlo Fed.rnl Rcgrlf,rion\ (Tirlc (). Pdt6)
<br />Rcquncd krrcr oi Noliff,nii.n
<br />d^iryrh,r Ihc rcdcral rcguhrn,N a8ddnre,\bc{os rctrhv rc tror r|t'licdblclo lhh projccl
<br />-lccrliryrhrr
<br />I hrvc rcod rhisllPrlicur
<br />orrlimrcsnnd Shrc Laws rclolins lo hu
<br />rh)vc trrnlion.dtmp. y for iNpccrio,
<br />i,!r xn,l{r. rh.r rh. xh\r l lngrc( ri.o t'ly Birh illCiryrtr,l(in, ny
<br />nrivrsolrlrir Ciiyrtrd Counly lo cnrs utrxrllE
<br />r,ar.: 1. G'lbA0Dliffnl or Artnl Sirnxt
<br />1>,^.t{ h
<br />Underground
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Satety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondino / Groundino / UFER
<br />Torqueing
<br />Sub-Panels
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilinqs (T-Bar Rouoh)
<br />lvleter Release
<br />Rouqh 4/t619 isttv
<br />Service IVleter
<br />FINAL ro/C/fr AM
<br />Notes, Remarks, Etc
<br />COMMENTS
<br />Site-Work
<br />Transformers
<br />Air Conditioners
<br />I.ndo \ Nrfr
<br />Pcd tee namrt,rinl):
<br />II
<br />I
<br />--+-
<br />tt
|