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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI-CARATION
<br />I hcrchy ,ffirm undcr lcMlly of pcrrlry lhar I o ererpr ronr rhc conrtcron Lian* ljw fttr rhc roll0wing rcasotr (Scc.703l S
<br />Businc$ rln t\olcsion Code) Any Ciry or county which Btuncs a llemi r{, .rn{rud. alrd. impmw. dcmlth nr rrEn rn} ,
<br />slrucrurc. Frior ro ns nsu!nc., alsu rcquircs tlt oprliant for such pcrmn h fihd s8ncd siarlm lnd hc or sh. n liccn*d putsMr
<br />lo rhc provisbnr ofltF Conllrci{n's Liccn*d Liw (Ch,plcr 9, co'rnEncins eirh Srcrion 7(no.r Divisbn 3 oflhc Busincs\ and
<br />Polt$ions Corlc) or rhlr lt .r shc iicx.mpl rhcrcamm and thcbasis lor lhcalhscd.xcmflion. AnyviolationolSerhnT0:ll5 h, trny
<br />rrpli.anr rom t'.nnn subjels lte amlicaor io a cilil pcn,lry ol @r tur. lhe nvc hundred dollars ($5{D)
<br />-1.
<br />as o*ncr .f rhe prcpcny, or nry cnrdoyes wilh wascs as thcn v'h conp.nslion. will do lhc wort ud rhc {ndm is nol
<br />imcnldl or.ficrcd rorelc(SN 7044. B!\im*snd Pnrcssions Cixic] Th. co Ecror's t.icc.se ljv d,.* .or APl, to !n oencr of
<br />rhc Impcny wio hild\ $ inlhEs rL]Nn. rd rho des {ch si{ iinsclfor lrr$lInrrhrcr8h ht o hcr o*nchlloy..s.
<br />ttuvidcrl rh.t such nnrrolcnE ls m mr hrcnd.d or orlercd fo. slc. Il howcrcr thc tlilrlin! or itprnlcmd ir $ld Nithin onc }tr
<br />.r.otrFb E rrh Owncr Buiklcr will hrvc lhc hunlcn ol pnvin8 rhd h. .i dE did .ol huild or iqmK dt phpcny ror rlt null,s or
<br />l,sowncrolrheDmpcny.mcich\ivcly.(fuicrinEuirhliccnscdronrrrosroconsr.rrtErn,jttt(scc7044.Bu\int\r
<br />rnd I'h,ftr\i Cod.:ThcConiradolst,iccnscl-a*docsnor,ppl,boosnciofPro|Erry$hohuildsornn8)vcsIhcrcon.
<br />and wh. o 6cls lor s!.h proj(N wirh a commclon, Iiccnscd nurrulnr 6 rh.Contacrors Liccnt L,s)
<br />-l
<br />!mcxcmfl undcrSclio B &PC lorrhi\!.re,..
<br />-l
<br />horc aflj will tui lin d Ccnific.rc oi Cons.t ro Sclalfllurc for *ork . conp.nstion. as [ovidcd tor by ser ion ]?$ of lh.
<br />tabor Code. lor lhc xrformNe ofrhc w.rk for *hich $. ncnnn n nsued.
<br />-lhovcrndwillmainruineorrcr
<br />conrFns,lion itrsumncc. os rciuncd bysdn,n.lTmollhc Llbor Codc, for rhc,,c ormnccol
<br />rh. $ork for*hichlhn Fmir is iss*l. M, wortc* omncnsalion insur!recfficr ldPlicynun$ct re:
<br />tirl'.,1'^,.rf f-ocr"
<br />t.\. \.1.
<br />Icc ily rhnr in lhc Frhrmncc oI lhe work nn which thi\ P$m k is{rcd.I shrll nor cmployrtryrcrwn itr trnymlin.r
<br />$!srobcdim{hjcdrorhc{ork$(.onrnctrraltunhwso(Cnlibinii.a,sdcrhdrirlshouldhcn'msubjr-rturtr
<br />qoltcr coDpcnsarn,n In,vi\b.s olSdrion l7U)ol thc titior Codc- I +r11. fonhwirh mmll, $irh lhoe Pmli\ionr
<br />WI\RNIN(: Frllurc n, {c.urc *orkcr'conplnsdnr covcrllsr i\ !trhqlul. md \hrll \uhjccr an rnrlloycr ro dimitil Pcnrhic\ rnd
<br />rivil nir\ up t) oic hundrcd lh.u$nd dolLrs ($l(n.Ofir). in rJdirn{ kJ rh. co\r ol.onl'.n\rri,,i. datri8c(.s prcvid.d r rhr
<br />Sccrit'n:10?6olrhc tjhn Codc. inrcrcsl ond oltormy s fa\
<br />"$ul+ t 1 2018
<br />DECI,Af,AIION
<br />I hcNby afftrm undcr pcnahy of lcrjury rhar I m licn{rn undcr pmvision ofCtanlc.9 (ofrmRin8 with S€tlioo 7000}.rDiviri.n I
<br />or fic ausifts dnd Pbfcsio.s Code. ond my liccnsc i\ in tull rdN nnl cficcl.
<br />-,$UN
<br />B I oefl ? qrn-
<br />+J]-I!fB .-".^",, W,+..*.-
<br />I!]IIIBUCIIOMADINIAGINII
<br />I hcrby aijinn under Fnuhyorp.rjurythal lhoc i! a on(ruclion kndins ngcn.y fnr lhc pcrfonrrncc ofrhc work lor whichlhis pcrmi n
<br />is$cd(Scc 1097. Cir. C ).
<br />AISUCANLDECT,ASAIIIJN
<br />I hr.hy affim undcr pcnahy of perhr, ooe or th. fdlosing dcL,rl ions
<br />Dc@l i6n Pcrnirs Asb.$os Notificolion Fedcnl Rcsol,riiu. (Tirl.40, Prn6)
<br />Rcquircd hnc. of Ndi6catbn
<br />lat<tilfy lht'r I luvc r.i rhis ,pfli.itn md sldc lhd lhc lhrr inftn i,rr
<br />onliNnccslndShrcl-r*\rchringlohuilditrscon{ruclion- ! hcrcnyatrhorizt " .oftccr I asrerocomtlywirhallCilrrtrd Counry
<br />or rhn Ciry,tul C.untyro cnlct lpon rhc
<br />rhovc moliomd pmpeny lor i'isp..rn n purpoes
<br />ApDlicanl o. /\!onl SiBntrluft :a-;A--,
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Founlains
<br />Siqns (monument)
<br />Life Salety /Low Vollage
<br />Fire Alarm i Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueinq
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinos (Hard & Soffit Bouqh
<br />Ceilinos (T-Bar Rouqh)
<br />It/eler Release
<br />Rough Clzz[tQ.(/z(o
<br />Service lt/eter
<br />FINAL {/%fi6 9>Vs
<br />Notes, Remarks, Etc
<br />Sub-Panels
<br />Air Conditioners
<br />]toEsES&.lolltlNsarrrx
<br />DECIABAIION
<br />I hcrcby alllrm utrdcr lcnrlryolPrjory oic.frhc loll.wrn! dshmrionsl
<br />r"rtlr,u,r,",, R.g!JlLCOl3Ld?<r r:*ni,",
<br />I r,,lr,'. \,,nr'. _
<br />I ccnilyrh.l rhc fcdc ral rcs! lnr io.s rcBsrdin8 astEslos rcnnularc nolappli.ftlc ro rhis oojc$r
<br />'JUN It 1 ?o1E
<br />fT
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