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ELECTRICAL-INSPECTOR RECORD <br />APPBOVALS DATE ID/SIG.COMMENTS <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Salety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bonding / Grounding / UFER 10- r- /1 <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Rool Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilings (Hard & Solfit Rouqh <br />Ceilings (T-Bar Rough) <br />Meter Release <br />Rough idlJt{ld- r-l1 <br />Service Meter ril- t -/r <br />FINAL ld-K-r1 \ <br />Notes Remarks, Etc. <br />OWNER BUII,DER DELCARATION <br />I hcEhy arlm unJ.r p.nalry dr !f,rjury lhar I m cxcn tium lhc Co rel,r' Lienr ljw f.r rhc lduu*in8 r.asn (Se.ilr.ll.5 ( <br />Bu$n.ss dfli Pofc*Dn C,rlc): Ary Cily or Counly whi.h rcquircs . pcmrir t' onsrflrr, dlt.r, rqrrovc, &nnish or rcpan any <br />nrudurc. prul(' ils ssuak-.c. aho Equtcs rhc lrplicrd nrsdch Fm b uh a !^ncd srrenEnl lhar h.or sh. n intns.d pusuanr <br />r' thc pruvtDis f rll C.nk[u s Lf,cnri ti{ (Ch.prcr g. Conrnrn.'n! *irh S.r6on 7fiD ot Divrion ] ofrhc Burincs! <br />Irr.l.s$n( C(ic)or lhar lk orrhc i\cxemprrhc.clr nr Jrhchr$lorrtudllcs.JcxcmPtrn.Anyvidatn'trolSc.rir7o.ll5hy <br />lppli.a ili,ral].rm suhJ.crsrh. r0tli(anr tu rcrv,lp..alry.tnor nuc rhm livc hundrcd.lollns ($500) <br />:::lt <br />-I. <br />N lwnfi ot th. nrcFny. or my cry)loyccs * h *ag$ .r lhct q,L cont .erntn, will do rlr *ol* anJ ltE \t ulE n nor <br />intcfrl.\l or olttBl tu elc (Se.7044, Buri*s ahd PRr.sonr cdlc: Th. a:o,lradn r Lrcn€ llw dE\ mn qDly ro o*ncr or <br />rhc pn{Eny wlD bldds or ihfs)E\ rhc6,[ lrl wh,][s surh w)rt hinNcllor h.rclfol rhhu3h his or h.t owncmPl.y..s. <br />pr,vrlcd rh{ ruch imPt}v.mnls a mt hrorlal .r oficrcJ ntr solc lr. t$N{r, rhe h{iBin3 or 'qrokmnr is n,U wnhh oE F! <br />ol $'r{)ldrx,n. rh. Ow*r Builkr wdl hlr llE trrdo ol FUvinB rhlt tr or rh. nd nn t{iu or ni{rtuv. rhc pbFny tot tlE PrPs of <br />l. a\o*ncrol rhc pop.ny, rm c(lu$lrly conrrchn! w h l(ctrxrl e.rLd.t)F t) !on(ru.(h. nrl)Jc.r (S.. ?{}44- Buinc* <br />anl Pn)lc$rr C.J.: I hc C{ntrttr s Liccnsc l-rw doc( n.r lpnly h u own.r ot pn,!.ny qho hurld s d nlt)nrEs rhcrcon. <br />rnd wh, contkk nn such n'('jc.h wnh. crunka(ron, k.trsc,l pusurtrlhrhcC.nr!a.n,'\ l,ircnsc l-rw) <br />_I amcrcnpr undcr S.d <br />!u85E8A!A!rE!$r!OX <br />DECIIXAIIAN <br />I h.r.hy rfitrnun't.r Fnalryol $rjury onc olrhc folk'w6e dcchrdlFnr <br />-l <br />hlv. lri *nl tu,nrin . Crcnifr.t. ofconscnt to S.lf:Insur.lor w .n' comFos{n,n, .s F.vid.d tur bySelm. -l?00ofthc <br />Labin Cdtl., ldr rh. ,xdnrukc of rh. wod( fn *ti(h th. Il.mlil n nsu.J <br />I hav. $d wrll md0lar workc e.mpcnsatnln inruriNc. rs rqtlircJ hy S(i on .1700 ol rh. tlbor Q c. Lr rhc tcrlolmne ol <br />ich rhr J'{r.nr s issNl My *orkcr' .on{Ensaron surrn.c urrr iJrl Frlry Nmhcr d. <br />t t-l-p <br />{ <br />l.cnifyrhal in lhc ll.rhrmn.c ol rhc wo turwhtrhrhN It rhi t Fsuc,l,I sh.U fr{ cmnl'}y.nyI'cnon rnany mrkr <br />\, a. b h.$m \uht cr ro rhc woRdr comFnsahn [u(.tCa nmn. lnd aEEe rhrr,fl sh)uld h(oft suhj.cl ln tlr <br />work.^.rn,F_r\nrn,ntr,v'notr(olSccrrJnJT([,olrhcl-niitr(iitclrhrll,l,,nh*nhlundywlr <br />WARNIN(;, l:r'lur. i) \.!uft sorkfl\ con,Nn\rrotr .!!v. !. tr r rr 6mlml mmlrrund <br />flv'l llnc\ up t) oDc hun'lrrJ rh, <br />ur!!:!-!!t!1r\ <br />I h.ehy.lftrnrnnd.r Fn.ltyol pcrjury rh.rI am lien$'l untlcr pfl)llnon orchafl.r 9 (onmftin8 q hSerm 1)00)olDivnn,n l <br />ol rh. Busimsl d Ptuf.sions Cod.,.nd my lrcne r m tu ll tbr.! ard clfe-.i. <br />L.t@ <br />l/' <br />I hcrcby.rltnu c! Nnallyof pcrjuryrh <br />NsucJ (S.r. 1097, Civ. C.) <br />nnfl.rxr Ln'lh! +cn(y ld ihc Fr,nrnun.c ofrhc work l,tr wh(h rhtr ltrh r <br />lrn&r't N,N'- <br />A!&ICANLIIECI,IIEAII9! <br />Ihc,$yanimn cr n nllryol pcriuryoncoirh.tull()wini J..lriLonv <br />txnnn r'. P.rnnr*Asb.nns Nonrrcarrn r.dcal Rcptrl.ttr)nr (lirlc40. Prrj6) <br />ll.!!tr.J IrrL! !'l N,i'lndiI <br />I r.n'ly rhrr rh. r.nc'rl r+!LLon\ndr iplrlrc.blc h rhr p!)jccr <br />lo.omtly wirh allCiry rnd Couory <br />ol rhs Crly and CounrYb cnrs tli)nrh. <br />-D3-( ? <br />ImI <br />r.l-0()l <br />=