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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE COMMENTS OWNEN SUILDOR DELCARATION
<br />I hcrcby lafirm undcr Fnalry {)t lcrjnry rhar I d srcnfl fmn rhc Conrict'E Liccns tiw ntr lhc follo{in8 rca$. lscc.7o:ll 5
<br />Aurin.ss ,nd Pmf.ssion Codc): Any Cit, or CoDnly whi.h nqunc. r frmir ro o.$ru.1. ulrcr. inpovc. &'mlhh .r'mrril any
<br />sructurc, pior to irs issulncc, aho rcquircs rhcaprlictrnt ior suchpcrnirro lll. r \igncd {,r.mni rhor tror shl i\ li.cnsd plruad
<br />b Ih. ptuv(ions or rh. Contri.ror's Li.cnscd bw (Chrprcr 9. Commcncin8 silh Sccrion 7(x)0 of Divhion .1 of rhc Bxsincss nnd
<br />Profc$ions Codc) or rhar lr or shc iscrcn r rhcrctor ond thc Msh lor rhc alkscd dehprion Any viol,rion orsccootr ?0ll.5 by any
<br />amlicanr l apcmrir subjslsrhe dprlic!fl x, acivilpenrlryofnor tu)( rhan 6vc hundr.d dollds(J500).
<br />l. ,c oeftr .f rhc pn,Fny, .r ny cmploy..s wirh w,!.s d\ rh.n s)b .onp.nel ion. will do llr wdk md rhc slturutu is M
<br />i cndcd orofcrcd for $lc (SN.?0.1,4, Busircssond Pmlcssions Codc rhc Coftncrors t-i..n\c txw docs n.r mnly lo !n owmr or
<br />rh. nnJrMy who hoildsor in$i.vcs llrron. ond who de\ such *o* him\clfor hcRlf or rhfruAh hh or hd.wn cnfhyccs.
<br />pn,vidcd rh r such inEoemnrs d c nol inkfrll{ r ofiL*l f(tr sh. la howev& lhe huiuina or imtrovcftd n skl *iihitr orc For
<br />ofconr0letion. rtE O*ncr Alihcr sill haw rlrc tDrd.n ol pmvins rh hc or \h. did n.r buih or impor lhc pmroly lor ll'E purlDsc oi
<br />-l-
<br />r\owncrollhc pro!.ny. !mcxclu\ivclyconlrrcrin8 sirh liccn$d..nrr.ktrs r)..trsfl.t rlE nn'ret lScc. ?(X4. Bu$ncs
<br />rnd ftrf.sion Codc: Thc Connrctoas Liccnsc Lor d.cs nol rpplylo inownc. olpml].dy sho huild\ or nnpovcs rh$&'n.
<br />rnd who conrrach tu slch pmjcck wirhaConrB.k(s)licen\cdptrFornr brhcQ)ntra.rols Liccnsc Low)
<br />-l
<br />a'n eremfl undcr S(rion
<br />uaf,KlBS:roMftiNtarrlJl!
<br />DECLAA rcN
<br />I hcrchy allirnr und.r pcnallyoipcrjury orc oflhc n'lhwinB dcclaruri,,N:
<br />-lhnve..dwillmoinl.irrCcnificarcolConsenrroSclilnsurcrhrqorkcrsonpc.\rrnnr,uspn,vidcdlarbyserionlT(rooithcUh.r C.dd. for rhc p.rfonnan( .f !h. $o* lor *hi.h thc p.flnn is h$rcd.
<br />-l
<br />nrvc! qill mninrain workcni coDlcrsrli.n i.suBncc. !s rcqutcd hy Scc(ion.l70Oofrhc trhor G)dc. for thc p.rlonumcc ol
<br />lhc $.rk lnr s[ich rhnpcnnil i\ i\sucJ My*..kc 'orlrprnvri.tr i.sunn...ndicr rlrl Fnicy nun$cr arc
<br />c
<br />P"tic\ N!n*l--]f!!zhn)2-a.4 0+,IJ
<br />lccnifyrhari',rhepcrr(rnnic.ofrhcw.rkforwhichrhispc nir is hncLl.I shalln.r cnUloylnt p..vnr ii atr,ranncr
<br />sr .s lo hc<rrc subjc.t to thc vorkcn onDctrsrtion law\ olCrlilnnin. lnd aaruc rhar irl shuuld l$onf, sunii lo rhc
<br />qnkd s comEnsation nn'visions ol Scdion :17(x) ot rhe Lllnr Q c. l shrll. lbnhwnh c. dy s irh rhoe fmli\ion! .
<br />$ARNIN(;: FrlLtrc ki {curu sorltr^ roi\f,tr\rrnn,.orcrxg. i\ trn ltl. .nd sh0ll sunicr rn cnrpl.jlr ki fi'nnrlN.rlri6 utrd
<br />civil fidc\ xt, h onc hututrcd rhou\rn{l dollar\ ($l(D.(Xx)). nr addir ns.lion. d,trug.\ r\ p(,vidcd for rhc
<br />:',-:-''4j.;Iru""
<br />I hcrcby lllnn undc{r.trrlr, of t'crjury d.l I m licus{ u.dcr rol (hrpr.r9r.lnnarmi ! sili S..ri(in rrxX)r.l'l)lvi\ion l
<br />of Ihc Businds\and Pn,fcrsions Codc. ond my lken* is in fullfor.c rd clIsr-b 1ef?'+Zb
<br />4ltaltlt
<br />I hftby rfiim lndcr lEnaht of,,erj!ry th.r rhm k ! oflstru.rion hnding ,Eeicy ror !h. Frlomncc ol lhc work for whnh tht rEmn is
<br />ksu.d (scc.1097, Civ. C.)
<br />trmlca\ Namr
<br />)
<br />AIPIICANIDESAAAIION
<br />I hmby dtirmund.r p.n0hy of pcrjury onc of lhc followinS dcclaElions:
<br />Dd.blirn,n Pdoirr Asb. os Norin.nrio. Fcde.rl Rc&trlario6! lTirlc 40. Pd6)
<br />-Rcquncd
<br />trrtcr orNoIfi coliotr
<br />_l..niiyrhrr rtu iidcralrcgrhrnnr rtrdin! a\h((o\ rctrxrrlri(. mr afi,licnhh h) rhr Dm].cl
<br />l( iryrhrr I turcrcrd rhndttli.dirinrtolnnrc ion i\.oncd lasrahcompl,sirhtrllCirr.i c.u ry
<br />o'di' ,..\ r Srxtr l-r*\ '.lxl0A nl rcpr.\cnrrrivc{ ollhi\ Ciry rtrtl cohry k, rirrr urx,r rhc
<br />Jhrc nEnrion.J Imncny lor
<br />,\ppli,rrl orAgotrl SiAnrlu ^,,, 11rc\rc
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool, Founlains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Bonding / Groundinq / UFER
<br />Translormers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)4/t//3 t /tot*+ I t1-
<br />Walls (Rough)tdz"/rt I 2*tc*ye-"r--Ceilings (Hard & Soffit Rouoh ,1r/15/te /DL
<br />Ceilinqs (T-Bar Rouoh),/Art/tC E?1Lrra.^-/c>,
<br />It/eter Release [ ' (,t '
<br />Rouqh td>olt I E"{rVt'Z-?
<br />Service ltlleter ,l
<br />FINAL bP aao:le'
<br />N es, Rema Etc.
<br />ID/SIG.
<br />Pole Bases
<br />Under Slab / Floor
<br />II
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