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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE tD/srG.COMMENTS OWNER BUILDER DELCAR{TION
<br />I hcrcby atfirn !.dd pcnrlry ol peijury rh l m cicmnr 6om thc ContracroF l,ice.e ljw for rhc rolLrinC rca$tr (s...701 1 .5
<br />ansincss md Prof.srion Cod.) Any Ciry or Co! y wlth ,quircs r Fmir ro 6n{fld. ahci. intmvc. dcmlish or mrrt My
<br />struclurc. prior ro ic nsuoncc, olso rcquircs rhc .lplicd ld such ttrnir ro nh . signcd Nlrc.h lhal hc or shc b lienscd Nlsuml
<br />ro rhc nmrisioni .frtu Conrra.'oas l-i..ned trw (Chtrrrcr 9, Connrcncins wirh Sc.iion 7(xn Df Divtio.I ol rh. Busin.ss rnd
<br />Pmlcssiotrs Cod.) or rh.t h. or shc h cxcnq lh.rcrr.m a.d lhc basis for rh. all.ecd cx.mprion. Any viol,lion ofScclion?011.5 by nny
<br />applic0nl ior opcrnrir subjcckthc aDpli.anl lo !civilp.nalryofool mElhan 6vc hundrct dolles (t500).
<br />_1. as owftr of thc ,n)rEny. r, m, cnployrc{ *irh wa8.\ as rh€ir slc compcBdt,n. will do the {ork md dr sturm n n
<br />i'n.ndcd or olTcrcd t . ek (Sa 7cr.l4, Bxsimss lnd Pm,'c$io s Codc rh. Conlmdor's Liccn\c tiw docs nor apnlylo !n owncr of
<br />rhc Impcny ehohildsor improvs rhcmtr, and wh) do. snch Mnk hinBcll or h$slf or thiorgh hh or hcr own cmrtoyc.s.
<br />,rolidcd rhll such imprclcmnls e not inbtuLd n of.rcn for sL ll h,wcrr. rh hoihirS or inpmlcmd h $ld vilhin nnc r
<br />ol'complction. rnc Osrc! Buildcr will havc th. hurd.. of Obling rid i. o. sh. did Nr bild or iqmvc Llc pmp.iy tor rhc ptrrF,s of
<br />l.3so*ncr oflhc prep.ny. amciclusitly.onrroclitrB wilh li.cnkd contnctrtrrk' Nn\ltocr rlE pnrFl (Scc.7O14, Burtu$
<br />and Pnfcsbn c()d.: Thc Contrroas l-i..nsc Lrw ildr ior aplly ro sn o*ncr ofpnrFny rho buildr.r imrmvcs lhc.co..
<br />dnd lho conrmch for slch lrn)jcctl with a Conrmcroi, liccnscd puruanfio rhc Contrcior's Liccns L.w).
<br />-l
<br />ancxcmpr undcr Sd B & P.C r'orrhl\ rcrv,n
<br />uo[trEas]:ouf[Nsall(,N
<br />DI:CIAAAIIA!
<br />I hcrcty ufiirnundcr pcnally otpcrjuryonc oilhc nnn,wir8 dNlIarbns:
<br />-l
<br />havc ,,n will rointli, r Ccnn_rcarc of Con*nr lo scll-l,aure ror workss .ompcnsorion. is lovidcd for hy Ssrion :l?00 of rhc
<br />Lohor Codc. for lh. Frlo.mancc ofrft wo.t for shi.h rlr lsnir ir isru.d.
<br />-l
<br />h.vc ud qill nridnin *.rkcs'c.m0cns t,n rsuraR.c. rs rcquncd by SL{ri6n l70O ofrh.ljhoi Cudc. f.r rh. Fr,onhn.c.f
<br />thc work fownichlht pcrmit is issucd Myworkcs')n nNurn.cc.rnrcr 0rxi Fnicy numbcr 0.
<br />-t.cdirylhal
<br />ir rhc!.rfonrLn.coflic w.r* lor whi.h is ptirnt is kucd,I shnllno' crnploynnypcnon inany mmncr
<br />v' s r{, lEconE sub]cd lo lhc *orkc compcnstn'n hws oi Ctrli{orri0. mdurrccrhar ilI snouu tirom slhjcd k,rhc
<br />wo,kcri conrcNolion pmvhions of Sccr ion l?m ol lhc Lrlnr ( odc- I slllll. tunhwirh conrly wilh lhoE rrDvhi.ns
<br />WAININC hilurc ro sur. workcr' con{f,nsrion .orr0gc n utrhwful. and sholl sul,rccl on cmtloycr ro fli'ninal ll.mlrts ard
<br />civil fiics uI' lo orc hundrcd rhousnd dollss (Slm.fl$I. in ddirion ro th. cosr olcomrcasorion. drm3es as plovided for rhc
<br />sccrn,n.10T6 ofrhc l-!horCodc. inrclcnend atrormy.s ncs.
<br />n4/zaU6 Appr.' ! De,G n
<br />UIINSDD.I:ONIBA.qBA
<br />l,Eo.daAlMN
<br />J7,1' 4 i<t
<br />I hcrcbyrllir undcr pcnalryoffcrjurr rh,r I am lic.nsn tndcr povision olChrrrcr 9 (comnrmin3 wirh S..rion 70m) ofDivi\ion:l
<br />of rl[ Bu\nrs dd Pofcsio's Codc. and my liccnse is i'r tull lh'c. xlcrfLcr.
<br />,61l111
<br />5/zq Ltb
<br />-r.i.nrr..to.:--
<br />Qc.ro'u ?r./t.t,rs
<br />COUSIBICUAtrIENUIG.AqENSI
<br />I turcby,flirn undcr Fnnlrr ol !.rjury thd 'htr is,.on*rrucrion knding,e.tuy for rhc pdro,mm. ofih. eo tuwhichlfihFamil is
<br />i*ucd{Sec lrD7. Civ C )
<br />ATII.IIANLIIIII/3AIIA!
<br />I rirhy 3ninn undcr Irmhyotpc.jury onc oirltr lnllo*ins dcclurolions
<br />l)cm'lirion Pcrmils Ashcslos Nolificarn'n fcdcral RcBularions (Iirle.l0. Pan6)
<br />R.qun.d l,crrdr oi Norillcrrion
<br />-l
<br />ccniiyrhd thclii.rolrc8ulurions rcaordins asbcslos rcnburl urc orapplicdblcr'rhhpmjccr
<br />I.cdifyrhar I hrle rc rhis rptlicrrnn,rnd drrcrh rhcrhnc infon,di,,, is.onccr I rArlr h (nnplt wirh rllCiryrid Counry
<br />odnlri.ds nid Surc ljw\ ltii.gbhiunr!con{rucri{in.anJhercbylrilarir.rcpr.\dnrdtivcsofrhi\CntridCdunryt'circru[inrh
<br />$ovc mtrrinred propcn, for in\pccrion
<br />Appll{ant or AaeDi SiaNlurc 4oe L<z ^,. 4zt/"
<br />Site-Work
<br />Unde rground
<br />Pole Bases
<br />Light Standards
<br />fuas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safe ty /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFEB
<br />folqueing
<br />Sub-Panels
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rouqh)
<br />[/eter Release r-
<br />Rough !- ltr I TUia+{q (I
<br />?-t-ig \.wv)
<br />Notes, Remarks , Elc.
<br />Translormers
<br />Air Conditioners
<br />Service [t/eter
<br />FINAL
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