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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNI'TI BUIT,DER DEI,CARATION
<br />I h6eb, .mm und€r p..ahy ol p.rjury that I m ereDpl ton the Contaro6 Licm l-aw lor th. tollowina r@n 1Sa.701 1 .5
<br />Busins anj ProfsFn Cod.) Any Cily or Colnry *hich requir6 . gnnit ia coNtdct, ah6. imFrovc d€nolish ot r.pair dy
<br />srrudurq pNr ro irs i*cu&c., aLo r.qrn6 lh. applicd fo! such p.flnn ro filc a sisncd slalqrol Ihal ft o, s}t is li.ascd p6irdt
<br />lo the rorisions ollhc Contacrors Li.d!.d Ll* (Chapr6 9, conm.ncin8 \ynh Sdrion 7000 of Division 3 ofthc BEin* 6nd
<br />Proa.sions codc) or thar hc or shc is cxempr rhe.from aad rhc basis lor rhe allesed *dnoion ;, iolorion oas.clion 7Oll.5 by.ny
<br />applicanrlorapnnitsubjtrrslhcapplic.mroaciviltd.hyornormor.thdt!.hundrcddolles(t500'
<br />l.6 o\nr olrhc pmp€ny. or my€nDloy6 NilhNas6 as lhen sk conp.6arion, $ill do rh. wo.I md $. studue is nol
<br />idlq.ted o. oll6.d ror ele (s* ?o44, BEin6 ed Pioasnrns cddc: Th. CofliE.kr's l.icms l-{s do6 nol 6rPl, ro d oNnd of
<br />thepspqly Lvho h,ilds{r i'nl,ov6 rh6o.. tud who d(E such soa hnns.lfot ncrc.lfor$nuSfi fiis or h6 asd mplot.6.
<br />ptuvidcd rh.t $rch inDrors]rfu 6c ml inrddrd o. ofl6.d lo,slc.I[ hoB6(. trB hlilding or in{rovdrcnl issld sithinonc}@
<br />of conplction. rhr OMs Buildr rvill have rh. hldcn of Forinr rha hc or sh. did nol build or i,qrovc the pmpqly for lh. l,utpos ol
<br />l. s osnd oathc propdy, an €$l$iv€ly conr.ctinS with licc$rd conurcros ro coErru.l th€ rojer (Sd 7044, &Ens
<br />dd Prof.ssion Codc:Ihc ContBtor\ l-i.cns. Law dod oot applylo e.wn$ oilro|xny*ho builds or impro!.s th6on.
<br />and who .ommG for $.h pmjds virh a CoirEro(9 licdrd puGuatn ro rh. Co.radoas LEdc Law)
<br />DEC!4aAr!OX
<br />I hdeby amm undd porhy of pdju., on€ olthc folloBi.r dalddionsl
<br />I h.!. a.d \rill nDintain . Cslificarc oacoNdtlo Self-lNnrc fo, s o,k6 mlnposrion- 6 Forid.! for b, Sdlion ] 700 oflfi.
<br />I-ibor Code aor rhc pdloman c o f rhc wmt for *hich lh. pcrnn b issxcd.
<br />I havc and will Dainhin worl.6 cor.lEsarion insurancc. as requtcdbys{rionrT00oarhcbborcodc.fo!thepelomanceof
<br />lhc $ort lor Nhich lhis p<mil is bsu.d. MyM.k6 on$qetion iqsuran...drd dxl polic, numbd 6c
<br />I cniayrhdr inrhcpdaoman .oalhewor[ aar whi.hrhis pemii is issued., shall not €mployanyp€6on in anymm.d
<br />e 6to b€.onE subjd to rhc *ort6 c.np.astion lass ol( alifomifl. dd as6 thar ill shotrld bdome subjd lo th.
<br />*orksl compmstion previsbns ofS.rlion 3700oirhc lrbor Code,l shlil ronhNith.ornply wilh lhos provisions.
<br />WARNINGT failurc lo Kurc rvo,k6 conpasalion covasc is unlawtuL dd shall subjd e mployr ro simina] p<Ehie tud
<br />cilil fincs up to one hundr.d lhouand doum (!100.000). in addilion to thc co$ of co6!.Mtion, damgG a providct for the
<br />Z
<br />I hseb, affinn und{ pcialryofFriuryrhar I
<br />o[(t aAllo!
<br />u.d.r prois noach.ph e(conn S{ri0n 7000).f Div,sion ll
<br />of ihc UusnEs and Pn,f6sn,N('odc
<br />cotslBuqrlolrElDlrcaqElr0
<br />I hoi!, rfm !nd6 p.nah, of p.qury lh.l thd€ t a connrudion LndinB osdcy lor thc p6looM.. ollhc work tur "tkh lhir Fnil i3
<br />issucd {S.c. 1097. Civ. C.).
<br />APPI ICAN'I' DE('I,ARATION
<br />I lE&y.mm lndd ptraky of pdjury one olthc follo*in-! del-dions:
<br />DeNl ion Pmirs Ash6ros Notifi.alion F€dral R.sularions (Tir1.,10, Pan6)
<br />RequtrnI Lcrler of Norifi carion
<br />I .d1iay rld rhe acddal r+ulnlions rcB dins db6kN rcnroral are nor .pplicable r. rhis trojrr.
<br />Iccnifythar I h crcadthisoppl'caxoned(alerhalrh.alinein LBrd io.onrpl, \rirh all( iryand County
<br />ordinflnc$ and Statc L.\vsrelatiDs to tn,ildiiE conslru.tt'n- d he,ebya
<br />aborc flmrional ,mpEl! lor
<br />P",^,r* ,,,," en.n /
<br />ofrhisCnymd Counry lo 716 upon rh.
<br />-*-,, t t/z+-/rf
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rough
<br />Ceilings (T-Bar Rouoh)
<br />Meter Release
<br />Rough
<br />Service lvleter
<br />FINAL 2-L1- 2.
<br />'e{
<br />I €rr
<br />Notes, Remarks, Etc
<br />I @.x.mDr uDdd Sd,on
<br />".'/J422y'1
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