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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDEN DDLCARATION
<br />I her€h, lffi.m uadcr Fnalry of perjury rhar I !m ci€trr,, 6om rhc CoirradoN Liccn.c Lrw for rh. folhain8 rcabn (S.c.7031.5
<br />Busincss .rd Phf.ssion Cod.): Any Ciry or Colnry which ,€quier r Fmir ro on{tu r. drd. iqrovc, dcnmlhh or rq[ii aoy
<br />ddcrui., prior to ns issuancc. also rcqutcs rltr applicmr lor su.h p.rmir ro nlc 0 siBmd stotcnEnt lhol hc or snc ir lic.nsd pu^nmr
<br />ro rh. pn,vnkrs ofllE Con"a.rors Lienscd Lrw (Ch,rler 9, Comncn.ing wirh sc.rion 70oo ol Dilision ] of thc Bu\incs and
<br />PhL$i.ns Cod.) or {har rr.r shc is.xcnpr rh.rcf.on.nd rh. basa\ for rh. aucgcd cxcmplion Atryviollliono{Seclhn 7011.5 bya.,
<br />{rplicantforapcninsbjekrhc.ppli.Mlroacivilp.n,krolnornDrcrhanivchurdrcddollus($500).
<br />_l- 6 owrc. of rhe rroFdr. or my entlotrcs wirh uascs as rhct slc .oopcn\ariun. will do rh. wdk dld thc nmlE k ftn
<br />inr.nLd or ollcr.d for srh ( so 7044. Businc* and ftofc$ions c.dc Thc Cotu ctois Lkn\c ljw docs nor lpply t, an owft. of
<br />rh.pmFny $ho blilds or nnpmws lhcm[ and who d.6 flch m hnnsc)forhciscllorrhDughhno,ncrowncoflorrcs.
<br />,rovidcd rhat such inlmEmnh @ mr inredcd ffoi].rd nneh lt ho*eri rlle t{ildin! or idtre\rftm issk snhitrnnc }rs
<br />oron{,hrirn- rrE ownn Buildd vill htrv. rhmh.ofFovin!rhdfuorshcdiimrI ld or iqmr thc pmFny 16r 'lt pxrtbe or
<br />-1.
<br />rs .wm. of rh( tmpcn y. am crclusivcly .ootocrin8 wirh li.cn*d .onrm.ton ro consrrucl rlE ptr,jcr (S.c 7fi.,r. 8u\ik\\
<br />nnd fisfs{b, C.dcr Thc Conracioas Lic.trsc tjw docs nor nftly ro nown.r ol lropcrlywho b.ildsor imrovcs rhcrco..
<br />a.d who conrBck for such phjecb wirh a Coot,cton r) licc nsed po xnd r. rhc conhtn\ Lic.ns ljw).
<br />lrD,rr.r,frunJ.r S..riir, .a &PC lnrrh\rcn!!,
<br />l)rlr O{nrr
<br />ul)8trE&s.c9-atPiNtallltB
<br />IlEclAa IIa!
<br />I hcrcbyniirmutrdcr pcmllyolFrjuryotrc.tlhcnnhsin8dcclmrions
<br />-lhlvcondwillnuinrainaC.nifraEotconenrkSclalnsurcfor*orkc6comr.ns,rio6.rspn,vidcdlorbySerion3?00oflhcL:bor Codc, for lh. pslbrmrcc oflhc wort for which lhe lmni is nsucd.
<br />I h{!c rnd sill tuinrtrin w6rk$a .onD.nir! im nruhncc. * rcqu ircd hy Sor ion 17(x) ol tfu tjhor Codc. lor rhc pertununcc of
<br />rlr ruk lar sh;ch rhn Fnnir is is\ucrl Nly ioi in\urmcc.rri.r ond policy nunrhL! arc
<br />-lccnifylhrl
<br />inthcpcrlbnun.cofrncwork whichrhi\ pcrmi n i$u.d.l \hdl not cnpbyany Frson inrnynr.nncr
<br />v, as k b..om subjdt to tu wo*Lrs .onp.nsdion hws otcrliforni{ md a8rcc rhrl ial sh,uld tE om \xbFr ro rh.
<br />eoltcB .onFns ionprovkions oiScclion lT0oofthc bti.r Colc,l shlll,lonhenhcomrly eiih rho€ pi(,!isn'ns
<br />W RNTN(i: Flilrrc t, E-.ur qorkc^' co,nliN{nn, coknsc is lihwful. r.d \hau sublc.l rn Mrti,}! to rininrlFnalri\ rDd
<br />civil fir\ up ro onc huidrcd rhousnnd dolla (il0!C.0O0). ii addirhn k,1hc.o( ol (.nlr.sarion. dartr8cs !\ proltlcd tur rhc
<br />Sc.rion:1076ofrhc lihor Cdlc. iircrc{ rnd dturfty s li{s
<br />-,", 5/z+/ |a ^n,,,.,,ir.rr"R.flffh* ?o(e'i;, s
<br />DECIAXAIION
<br />I hcrby afin6 undn !.n,lry or p.rjury lh,l I am Ii.cn*rl und.r pmvision ofCh0tra 9l.o'nnErcins silh Scclion 7lx)O) ofDivki.n -r
<br />of th€ Busirc$ and Pmiesridns Codc. md my licens i\ in flll fo(i dd cffc.r.
<br />aelc\r 1
<br />lllql fZ c*,-"*,Decro'-P.o4c. +', t5
<br />APPUCANfDECIAaAIION
<br />I hmby a]lmr und& Fnalty ol Frrury orc ol thc followin8 d.cldalions:
<br />D.' rinn Pcrnrils-Asb.doi Norificdion Fcd.rrl Rcgu ht ionr (Tirlc (). Pan6)
<br />Rrquirdd tr(cr of Norifimiion
<br />I ccnily rh,' rhc ltdcml rcEuLtiotrs rsudinB osbcnos rcmovnlarc nor afllicahlc ro rhn pmjecl
<br />I cdify rhd I hav. rcad rhis lptltarion ad sratc rhlt rhe {x,vc infornur ion ir corer L,!N r. L\,moly wilh trll Ciry .d Counly
<br />ordiMnccs md Sr0r. tiws Ehrins ro buildin-! connrucrion. !d hcrct y aurhorizc rcp,c*.rarivc\ olrh& Ciry ond Couflr, to cnts upon thc
<br />.hvc nriridrd pnrcny nn in\lr.tior
<br />ADt li."trl or A*.nl SiEnelur
<br />Pmrren.m.rprrno: 4t +/L
<br />s/z</6
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels 6-8 -(8,-f(Llal.rl r'4
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilinqs (Hard & Solfit Rouoh
<br />Ceilings (T-Bar Rough)
<br />Meter Release
<br />Rough ;./g-/9 -U"ltht';)
<br />Service It/eler /zr\
<br />FINAL 1-n-t$'rx.w-1u
<br />Notes, Remarks, Etc r v CONSTRU(:ToN I ENDIN(; ACENCA
<br />I h.Eby omrm uodcr lcmlly of pcrjur, thal lhqc is a onsrruclion hndnrs aseocy nx fie psnnMft. oflhc wort fot {hth rhis Frnril h
<br />hsu.d (sd. lm7.Civ. C.).
<br />tr.dcr'. \anF
<br />L.nd.l. Addre$.
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<br />Pole Bases
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