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ELECTRICAL-INSPECTOH RECORD
<br />DATE ID/SIG.COMMENTS OlVNER BUILDER DELCARATION
<br />I heret'y lmrm u ndcr rEnahy ol Frjury rhar I d ciempr trch rhc G)ntados Li.cns tiw for lhc followiq rca$n (Sc. 70.r l 5
<br />Bosinc$ arn Pmfcsioo C.d.): Any Cny or counry Ehi.h {qunc\ r F.mir to con(rucr. dlcr. impr.vc. d.ftrkh or rcprt atry
<br />sd.ruc. l,rff ro irs asnm.. *o rcquircs rhc !ptli., hr such p.rnil ro iilc a sisicd d,rcftnr rhal rf, or shc n licctrrcd Puruonl
<br />n, rhc pmvisions ol lhc Conrracroir t-i.co{d lnw (Chaprcr L Co'nnr..ine wirh Scclion 70u) of Divnion I oflhc Bu\inc* d
<br />Piorc\{ionsCod.)orrh,rtrorshchcxcnplrhcElio,nMdrhchlrkturrhcrllcscdcxcnDrion.Anyenrhri{,nofSetionT0ll5byrtry
<br />amlicanr l'or a !.nnir suhjccrsrhc apllicanr !, acivilpcnalryolnor mErhan fiv. hund6ddolldr l$50o).
<br />l. rs owrEr ollhc popcny. o! mycmployecs with wiscs $ lhen $t $frpcn{ridr, wilrdo lhc wolt and E (Mlure n nor
<br />irlcnlcd or olitrcd for elc (Ss.7044. Business and Pr.acssn,ns Codc: Thd Conradors Liccn* tie dcs nol amly ro an own.ror
<br />rhc pnD.ny *to t{ild. or ir{rows rh.mn. drd who dms shh Mft hinNcllor hcrcltor rhnu8h his o. hcr owo.mploy..s.
<br />orovdcd lhal such impmv.mnk m nor intnki or ofificd aor soh. l( h.scs. l,r t{ildins or ir{mkE L\ sld *irhrn onc }tr
<br />of.onDlcrbn, rh. Oeftr Bnild.. willtEE rlE burdcb of pbvin8 rhd h.or shc did mt toin or inlmrc thc pnrpcny for rlr purlns of
<br />-l-
<br />asowrcr.frItr Dnr.ny. lnrcrclu\ivc!,.onl&clins wilh liccnwl.o krct) t, .on{rucr rltr tmjd (Scc 7M4. Busnc$
<br />sid Pn,ftr\nnc(dc:'l h. Cont0.lor's Licctrsc Lnw d..s nor ittly t, atr osncr olfropcnywho huikl\ or imtmvcs rh.rcon,
<br />.nd who conrracrr t'o. such Irotcch wirh r Conrrld.nt liccnrd puFunrto rhc conkrrir\ Li.cr* tiw).
<br />- l n.xcnrpl trtulcr sccri{nr . a & |( lnrr[r\ tur\tri
<br />lhre ()encr
<br />laatrlts:s)lltENtallQN
<br />lr-qanalrQx
<br />I hcrchyorftnrundcrn nnltyolneiuly.tuoIrhcnnbwinsdcclxn n'ns
<br />-Ihi$mdBillnminraitr!CcniarcircofCon*nrtoSclf'ltrsurcforworkcrs
<br />coml,cDsarioo- r\ Irovided for hy Scclion]T0oorlhc
<br />L,bor Cod.. ro. rhc p.rrornmnc. ofrhc work for *hich rlE I.mn G ksucd
<br />-l
<br />hlvclndwillminlrin $o.kcr\' conpcn$rioa insurmcc- rs r.qon.d hrS0.ri,'n:17(xrorrhc liborOic. itrrhc Frrurn,R-dor
<br />lnc sorl tu shi.[ rhi!rnnir i\ A$d My*orlcn n\ari,trr i',suBtrr. .micr rtrd |Flicynunrbcr arc:
<br />lcunilyrhrr i',rh. porforntr'Kc ofrhc No ro. shich thi\ Il.nnir is issucd.l \h!ll n l cmpl,,y any lcrsn in.try m.nm.
<br />h as lo hccom su6jN x' lhc workc.( conFnsarion L$s orcalitunis, aid,8m rhar if I should hsom suhjccr ro rra
<br />*o.lcF.ompcnqrionIl!)lisbnsofs*r n.l?00 ufrh. tf,trr Cod..I sh.ll.,oniwirh omplyNirh rlDs pmvnion\
<br />WARNINC: llilurc to scu.c *orkc6 .oorpcnsari{,n srv.mBc is unlnwhil. and sh.ll suhj.tl .n cmtlorr lo si'ninrl lcMxi$ and
<br />civil fitrcs up to onc hundrcd lhousand doll$ (5100.0(x)). ir lddilbn (, rhc co{ ot comp.nsdion. d!'ugcs !\ Pmridcd ror !h€
<br />sc.rion 1016 of rhc tibor Codc, inrerest md fllormy s ltcs
<br />1/za / r1 CJ9!.P.-/'/i r'>
<br />DECI.AMIION
<br />I hcnb, ailirm undcr Fnally oI pcriury that I am lic€n{n und.r prcvkion orChrprd 9(comnEncine *itn Sccliotr 7000) olDivi\ioi l
<br />.f rh. Bnsine* und Phr.*ions codc. a myliccnsc is in tull forcc and cficcl.
<br />?a l.{tl
<br />6lL'.L4 fu.lot &agr.);t*
<br />COIIII!]IjIIAII.INDIXCACENCI
<br />I hcruby afinD undq Fcnally.I F.ru.y rhar rhcre n a condrucrb.Ic"di'r! trscn.y rot rhc rlfoirn!tre oflhc work ftn whi.h rhis Fnnir il
<br />issucd (Sc( 109?. Civ C.).
<br />AITIIIANLDICI.IIBAIION
<br />I hdrbyrmnnund.r p.mlty oIlcrjury orc of lhc follopinS dccltrr ions
<br />Dc.diriotr Pfinirs Asb.qos Norifi$rion Fcd.ral RcSuldions (Tnl.40. P!n6)
<br />_Rcquircd t tt rof Norificorioi
<br />l.difyth,r rhc lcdcrrl rcsulorions reslrdillg nrtEnos rcnmvslrrc noi arpli.ablc k) rhis tm]c.'
<br />-l
<br />ccniiyrhrr I hrvc rcad thi\ 4,!licart,n and irt rhar rhcah,!c inf.nn[ion s.or.d , iErN ro onrply *iri nll Cirt rM counly
<br />ordin!rccsand Srurc Lipsrchri.a!o bnildire.o.(ru.rnrn,,nd h.rchy 0xrlx izcrcprcscnrorilcsoarhisCnyandc.udryrocmcinronrtr
<br />ahovc nEntiorcd nm!.ny for insrccrion
<br />Apt l{mnt or Alcnt Sknnirrrc
<br />H"zo Lzft ^", 1/zq./t<
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels t- j -t8 ),\o5ft.I
<br />Air Conditioners
<br />Roof Top Equipmenl
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rough)
<br />Ivleter Release
<br />Rough I '-/z-E J /c-tido a 7
<br />Service Meter
<br />FINAL --1-la '.t y'oSoVz (t/
<br />Notes, Remarks, Etc.
<br />o-r 7
<br />APPROVALS
<br />/Irndn'\ Nsm.
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