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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDER DELCARA'TION
<br />I h.rcby trfirnt und6 p.n lrt rn pcrjury rhm l .nr cxctrrtr from rhc Conrrscr.N t-iccnsc ljs lor rh. nnbwi* rcN,n (s1!7011.5
<br />Burincs rnd ProLsion Code) Any Ciry or Counl, which rcquiEs u lcrmir t, .on{ru.r, nlrcr. inptovc. dcn{nnh o' rcprn 3ny
<br />slruclurc. prir to ils issu!rcc, ako rcqundsihc apdicsnr r(r \uch Pdnlil b filcn si8tred slllcmnl rhlr hcor shc ir lic.nscd Nsu.nr
<br />b thc pruvisions ollhc Contrclois Liccnscd kw (Chrylcr 9. GrDrnc cinE wirh S.cri TmO oa Divhion I ofrhc Businc\c,nd
<br />Pmlcssions Gdc) oi Ihlr tf, or she ir crcmpr rlu.rrom Md rh. bask ror rhc ,llc8cd cxcnfli.n. Aoy violari.nofscrbnT0:ll5 by dny
<br />rmli.rnrr(trrpcnnirslbj(arhc.mlican oac,!illcnoliyolnotnnrclh.nfivehundrcddoll,(l$50o)
<br />L rs owhcr olrhc nmFny. or mycmploles Nilh w!8cs os rhcn wh.omp.nern,n, *ill d. d. q.rl ud lnc (nrl,m ir nor
<br />i cndcd oro,larcd r'or slc (S(.?(},14, Brsitussnnd Prorc$ions C{ cr Thc conra.rol s Liens l,w docs hor dmly h o$nqof
<br />rhc rD|tny who brildso. n@mrcs lhcG)n. rnd wlD dm {'ch w)rk himsrltor hcrell.r IhmuAh ih o, hs osn.mployccs.
<br />providcd rhar such i,nEolc.rnrs m frn inrcMcd or ollcEd f.r sh ll lm$crcr. rlE t{ildi'rS ot inpmltmnr Ls s,ki sithir m
<br />'lror.onrplcrior. rtr OB mr Buildcr will horc lhc hldcn of l)rovins thol hc o. she did mi buitl or irpmvc lhc pmpcn, fr rhe I rIn{.r
<br />l-a\o$ncrofihcprcIcny.rr.x.lusivcly.onlr&ringsirhli.cnrcdconrEctnt)co{d.rrh.Pft)i.$(Sc7041,Bu\inc\\
<br />rtrd Piri:ssbtr Coic lhc Conrructn s l-i.cnsc l-rw doc\ iorllplyb No*rd oltrropcnyq'ho huildr orimpiovc\ rh$con.
<br />uid who d,n'm.rs ntr such tn*ch wilh 0 abtrtmdonn licctr*d purunl lo rhc Conr.acr.rs l-i.cnr. uw).
<br />_l a cxcnrpr h{tcr Scrini-. B. & P.C. forrht rc!$n
<br />Dole: O*m.:
<br />wonxrns' crwrpnrslttotr
<br />IECI.AIAIIO!
<br />I hcrchy aafirm undc, prnalryorporuryon. of'h. followinS d.clnrdnlns
<br />\:l+dc ud willminrsin,ccnrk0r.orcunanrro sclr.lnsur. lor workcr' coq,.nerion. !s pn,vidcd for by sccrion l?00 oflhc
<br />LaY a.!lc. rnrhe psfonmne otlhc M lo, *hkhlhcrr.mi i. n\u.n
<br />f r,or c a na *irr n, rnr in wo.kcr' lonI.nht mn
<br />'nsur!nc!,
<br />as rcqlicd by Sccr ion l?OO .f lhc Ljblr Codc. ror lhc pcdomurcc ol
<br />rhe *ork lor whkh lhis lcmn is isscd My sorkcs .onp.nsalion insur!rcc ca cr dd pli.y nlmb.r ml
<br />4
<br />I.cn,tyrh'ri'rrhcpcrfoflmnccofrhcso*hruhicnlhisncnniri\is\ued,Ishll .rcnrrloy y !.rson ir.nynunncr
<br />$ $r. hcomc n$jd rorhc worrss.\,nrpdtr\dn,n la*s or crliri,nir. da8rcc rhll il'l \hould h.um suhjet to rh.
<br />$or*c6 compcnsarionpo!i\i{,n\ ofs..ri(,.lTtDofrhc l,lhr Cbdc.l drll. tunhwiihcomply wirh !h){ povisions..
<br />wARNIN(;: F lurc ro ecurc sorkcr' conpenlll
<br />civil nncs xp lo onc hundrcd lhousand dolhrs ($
<br />Sc t rnl wfrl, rnd nrll \uhr$l an cmplord x' dimlnalFmlies and
<br />ion, draugcs oi providcd rb. Ihc
<br />s&l, 11176of rh. l]ltn.Crnlc inrcrc{and dror
<br />7-+" ty
<br />IECIASAIIIN
<br />I hmby afllrm und.r pcnllryofF+ry lhal I om lien$t undcr lrclisionotChtfl$ 9 (mmmrcin8 *ith Sdion 7000) otDivnion 3
<br />ot lhe Busims lnd PDfe*io.sCodc, ad ny liccnsc k in tullforc dcffccl.
<br />{_,=Y* ty
<br />CQNSIBU.(:IIONIENIIIIG.AC}:II.I
<br />Ihcrh,rrfinundfNnrllyofpcrjurylharrhcrcnaconslru.lhtrhdi'rga!.n.yrorrhcPcrlonrunccoirhcsorkr.rwhidhthis|Ernilis
<br />istrcd (Scc .1097. Civ C ).
<br />APTUCANfDEIIAAAII0N
<br />I hftrry drmn xnd€, Fnalry ofFrjuly orc ofrhc lollowing declmrions:
<br />Dcmlirion Pcrmih-AslEstos Norif@tion F.d.ral R.Buhrion (Tnl. .10. Pan6)
<br />-Rcquncd
<br />Lcrler ol Norif'cdion
<br />I.cn'ryrhnr rhc rcdcml rcsulrtions rc3{di'rE u\h!slo\ rcnn,vxltr'a Dor ntpltrrhlc h rhis Pmjccr
<br />I lc.nrtyrhrr I hr\r rcrd rhn rnn licrri,)nr \rxrcrhJrrh.rh,!. itrtun,uridr r .orc.l. l ll!ftr k).orlllly *irh rll(-irtntrd(i'unry
<br />odirrNcs md sr.rc ljws rlarir8 iurh.riz. rcprm rlncs ol this Cny and Coury to cntn utDn rhc
<br />xli)vr tr{nri,nE,l f'otrdy ntr
<br />\ppliunl or ,\xul Sixn l
<br />\\0(l t c-^,", f *T- lg
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundino / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soflit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />,,.\
<br />Roush fqpAr'Y^r{7'6"1t >rr)01
<br />Service lvleter \1
<br />FINAL /40-t 8 ,qA7)
<br />Notes, Remarks, Etc
<br />Ivleler Release
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