|
ELECTRICAL-INSPECTOR RECORD
<br />OIINER BUILDAR DELCARATION
<br />I h.rcby rflirnr trndcr ocfulry ot rErjury rhnr I i crenfl lm'. rh. ConrracroF Ltcn{ tjw t{n rhc rolhsing rcr$n (scc7r
<br />ausir.ss Md Prof.ssbn Cod.): Any Ciry o! Coutrty shi.h r.qrncs r tl.nnn Io .onslrud. alrcr, im[ovc. d.nmlhh nr rcI!{r
<br />{tucru'c. prtuk' il! isunnce. alw' rcquircs rh. alIli.lnl tu such lEnnil k, lih tr \igtrcd dirc'Enr rhxr hcor \hc is licctr€d fl61
<br />Io lhc povhiotrs of lhc Cotrractois Liccnrcd L.w (Cha/.r 9, ConrnENine wirh Scction ?(x)0 of Divhion :l ollhc Businc$ a'
<br />Pmn$hncCodcrorrharlrorshchcxcrrDllficrefro'n.ndlhch$nnrlhcilkcdcrcmrrion.AnyriollrionofseriohT0.ll5by
<br />appli.rnr lir.!p.nnils!bjElrrhc applica ro acivilpcnallyol nor mrcrhan fivc htrndrcddnllar(l5m)
<br />-1,
<br />us owncrof'hcponcnt.{rmrcnrnloyecs wirhwoScsasrhcn sohcompcnsrbn. ailldo ltE worl rxl lhc nDh is ml
<br />i.r.nicd or oficrcd for ele (S( 704.r, Businc\r and tlole$ions Codc: Thc Contrdctr\ Li..n* lls d.cs frn q'/y ro 0n owner ot
<br />thc trcpcdy wh. huilds or irymKs rhtm.. and who docs sch sork himscllor h.sclfor lhnu3h hic.r hcr own cmplorces,
<br />prorided rhnr such inrpro!!runk ft noi inrcndcd or offe(n lor slc lt howcq, rhc huitli.g or irflrctmnr k st] *nhin ',nc )Qr
<br />ol'..tr!)tliotr dc Owrcr Bliklcr wil hur tlrc tord.n ol pr.vinB lhd h. or stc di, mr l[ild or innnE 6e popcny f.r rhj l,uqBE ol
<br />-1.rsowtrcrollh.pror8ny.!mcrclu\ivclyconlruringwithliccnscdc.trrrsdoaloconnn
<br />nr proJ..r (Scc 704.,1, Bu\irtc$
<br />ldI'bf.\siiCodclh.ContnrofsL(crscLiwdocsnorrpplthan.wicrol|)(,rcdytrhohuilds..nnprorairi.rcon.
<br />lnd sho conrr& s for surh poiccr\ wirhaConrrrio(n liccnscd rur\urnr ro rhc L-otrtactn \ Lic.isc lrw).
<br />_l addcnpr undcr Secrio
<br />It0atrEBs-1;lllttENsa:Il1ltr
<br />DICI,I3AIIA!
<br />I hcahy rffiirn utrdcr Jl.nrlrt ofpcrruryoncofrtu nnbwing dc.lurrion\
<br />_lharrandsillnuiirain!CcnifEarcorconsdnrt,Scllln{rctorsorkcr'co'np.nr nrn,rc ttulidcd nn byScctn lTLxJoilhc
<br />lihor Codc. to, rhc,,crformncc oflie wort lor uhich rhc rcrn l t hsucd.
<br />Ihrlr nd { ill niintJn aork.ra .omrcnsatn insuranc., !s r.qrncd hyS.lrii l7mof rhc Lrbor Codc. lor thc p{nbrnunccoi
<br />rhc *ork turwhi.h rhi\ pcnnir is hiucd My work&f .umlrn$ri,,n in\xrn c..rricr d Flict trtrmhcr rc
<br />Poli.yNomb ExpiEs:
<br />I ccnify rhrr in thc,Bfoirntrtre ofrhc sork li,r qhrh rhR r.nni is i*ncd. ! shrll nol cnrloy (ny n!r(,n in atry n'rincr
<br />R, r\t'hcco'm sutjccrh rhcaorkc dnntr. rxrtnrirwsolCrlif nii. rtulrgturhirilI slhuld hc.otrf, i,hjcd rorhc
<br />w.rkc.i compcn\rrion prclniotrs ofSc.ri, l7(Xlolrhr tf,hr (ixlc,I \hrll. r.nhsnh ompl! $nh rho* Imvni.trs
<br />WARNINC: I:r lurc b {curc $orkcri conT.nsrri{in covcrrlc i\ unir*1i'|. rnd shrll srbjrd rr c rdrr"( t, dimir.l J[orlrc\ rnl
<br />cilil liDc\ up b onc hun.lrr{l rhou\rid doll*s (1lm,ffXr. in rddirn)n t) rh. c.{ ,'f .ont,cr\nnon. drnrAcs rs Dr)rnl.,l l,trrhc
<br />Scc.on :1076orrhc,rtxtrCodr. nt$c{ ud onEy'\ fccs
<br />DECIABAII!]N
<br />I hcrc$ynlfirmuMcr l,cnalt] o, Frjury lhat I am liccnsn undcr pmvision oachafler 9 (commncins,irh S.triJn T(xD) orDirGion l
<br />of rh. atrsift* and Pmf..sn,.s Codc, ind my liccnc h in tull lirm. &n cflact.
<br />LicenseClass-
<br />D"i...f-14*\: c*,*d..
<br />/."
<br />/*
<br />CO IiIBuqUONIENDINC.AGENqI
<br />I hcrct'y lllim uklcr pcnalry ol pcrjury rhar rhcr. i! ( conslruction hndins oscmy n, rhc pc.r.r.ramc otrhc work ior whthrhh r^-nnir is
<br />rsucd lsc. 1097,Civ C.)
<br />AIII]CANLDEI;IAAAIION
<br />I H,y Ininn undcr I,cnrhyof pcrFry onc oarhe tollo*ins dalsalions:
<br />Dcmolitun Pernits.Ash.sros Notilicarbn ftderul Rcgulstions (Tillc 40. Pd6)
<br />-Rcquircd
<br />t llcrof Norifrotirn
<br />-l
<br />ccnilyrh0r rhc lcdcnl lc8ulations rcssdins AstEsros rcnDv0l$c norlpplioblc ro rhis tr.Jlcr
<br />Iccnifrrh l hrlc rcrd rhi\applicarid rtul err.rhdrhcrtI)vc inaormdnnr i\.drc(r IrprNr,co.rfly!irhallCilyandCouniy
<br />.rdinricd\nndSrdr.Ijw\rl ii!robuildirg.onsrndnnrd hcrby rurh riz. rqn$c ivc\.fthisCiryrndCounryro.nrst,r)ith.
<br />Aprli(! or Alcnr siEn!rurc
<br />APPFOVALS DATE COMMENTS
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Solf it Rouqh
<br />Ceilings (T-Bar Rough)
<br />It/eter Release
<br />Rough I --r
<br />Service Meter q tutff />tN\)
<br />FINAL )7util
<br />Notes Remarks Etc.
<br />-t
<br />Ftro.sle4 Ld"dLL *,",o8-ttl+-t3
<br />ID/SIG.
<br />,,,", ,, - tt+-\8
<br />rbvc ntrnrn,ncd nr)pcny nr i',\pc.ri{,n turpo\cs
|