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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS ID/SIG.COMMENTS OWNER B('II,DER DELCARATIoN
<br />I hcr€by !finn undcr Fn.hy of Frjury lhlt I 0n cx.nq from lh. c.nrro6 Li.cn€ Ijw for lhc iollowir8 rcason (S(.?01 1 .5
<br />Businc$ md Profcssnnr Codc): Any Ciry or Counly which rcqun* , IEirnil to $n\lrucl. olln. in{rove. dcmolish or rcpan Bny
<br />{tucrur.. rinb ns i$r,mc. also rcqutcs rhcapplicd nx suchrcmirto filca sisncd sra'cmnr rhar hcorshe i{ lien..{ pumMr
<br />ro rh. pn,visions otlhc Co.ldror's l-iccnscd ljs (Chlplcr 9. (.onnncrcins wilh Secrion T(tXr of Divhion I ol rh. Bu\incs ud
<br />Pofcssionr C.dc)orihdrh.orshc is.rcmtr lh.i.fonnnd rh. hasir forrhcallcA.d.rcmprion A.yvi,l n,.orscdionT0.ll5byany
<br />(lpli.anr lor0lx rn subjccls lhc ptlicanl loa.,rilpcnaltyornol nmBrha fivc hundrcd dollrs (55ID,
<br />l. rs osNr of rh. pn)trdt, or my cmphres wn h wrgr( ,r rh.ir k,lc co.rFn\.ri(fl. sill du rh. wtrl drl tlr ntrtrrc i ml
<br />inlcalsl or ofcrcd for mh (Sa r0l4. gusincs and ftoiassions Codcr Thc Conlrrcrols Liccne tzw docs trot lPlly lo mowncr oi
<br />rh. pmFny wrr hrilds o. itrI,mB rtEBn!. ad who d.rs such Nd( hin$cltor hcrsltor rhroush th or herosn citloyc.s,
<br />providcd rhar su.h inqhEnrnb m nor inrc klcd or orcrsd firqlc.lf. b*rvcr rh€ h dinE or iq,oknnr is $ki *irh'nuR )tr
<br />ol.nmthrhn. rh. Owncr Buikl$ willlxrvc rhc burddn oflmvin8 rhd hc or shc did nor l.iln or iq,row rhc pmFiy fo' r]E rrqh$ of
<br />_1. r\owncr oirhc lopeny.0mcxclurivcly conlnclin8 wirh licctrkd conrrodoN ro on\rrucr rh. lnjccr (S.c.7(84. Bu\inc*
<br />. I\!,f*siD Cod. Thc Conractoi s Li.cn\. Iiw do.! ,or nrpl, ro an owrc. of pn)pcd y who build. o. imtovc\ rhcr.on.
<br />and who rotrhcrsld ruch pmjecc sirh r tnnh.ro(s) li..trs.d pxrsuml rorhcConricrois Liccns tiw).
<br />-l0mcxenrpt
<br />undcr Sccrion-. A & P.C. fd rhis rc8$n
<br />uQB6[&ll:OuUiNtA.rON
<br />DECIAI^IIOd
<br />I hcrchy rltum trMcr lcnrhyolrreluryonc olrhc followir8 dc.lar.tnJns
<br />-l
<br />havc arxt will 'minllin r CcniaEarc.iCo"rnl to Sclf.lnnrc lor sorkcra con{Ensation- !s pmvidcd Lr bySccrionlTCnorrhc
<br />llbor Code- for lnc ,,ql'orNrcc oI rhc wo,k for *hich lhc pcflnil k isucd
<br />r lr \ ork lar q hi.h rhn Nrnir is n Lt Nly $or kc^' $nrNd\rr i,in i'Nufltrrc .r' r{r rRl fili.! nrnrlf,r dc
<br />-l.unifyrl
<br />illhcpdrairMtrccoillEworkr'or*hichrni\rc nir n isucd.I \hilltrorcmtn{)yroy pcron in xny nrnncr
<br />*, r\ h lr.onr.lu$jcd n, rh. sorkcr\'.onf.i\,i{,n h$s oi( Jlilbn,i( itrd 3!r.r rhar ifl \hoold hconr {rhlc.r ro rhr
<br />*.rkc^ con,F-.n\trt i,in polisnrn\ of S..rid :1700 of rlf l isir Codc. l \h!ll. nfl hwir h .. ' y wirh rho* rn,vis'on(
<br />WARNIN(;: Frihrc b {cuto tr(nk.r\ conBn\dn .ovcrr8c is ufl wful. rid \hall suh}j.r ,r c Dloycr ro nnniml p.nrhi.s ann
<br />civil fitrc\ up b on. hundrcd th.usinrl dolldn ($loo.fiX). in ddirio. r, thc..{ of.omFtr! n r. drnngcs !\ Ir.vidcd ntr ric
<br />Sc.rion 1076 Irlt Latn Clilc. inrcrcs itrd irionf,y s fo\
<br />Applit nl:
<br />uctxslLcoNra .qaa
<br />DECLIXAJ0Ii
<br />CONEIBUCII{JNIENDINq&GENCI
<br />I hcrchy ailtmuMcr p.nallyoipcrjurylhd rhcrc G 0 otrsrucrbn lcnding a8crcy for thc r.rfonim.. olrhc aort for whi.h lht rsnil h
<br />issucd (Scc.1097.Civ C ).
<br />AIPIICANII]ECI.ASAIIIJN
<br />I lErtry dtu xnd.r Fndlry orFrju.y om orrh. ro,bwing dsle.rion\:
<br />Dcmnition Pcrn ts'Asbcsros Nolificltion Fedcrll RcEulsrion\ lTnt 40. Pan6)
<br />-Rcquicd
<br />t.ncr of Norificolion
<br />-l
<br />ccnily rn,t rhc rcdc..l rcEUn iotrs rgadnrS lstE{o c k,valtuc tror rt dt,blc h tht nmjccl
<br />l ..nifr rhat I hn\r rcad rhi\ +plic ion rn {ar. rhd rhc rtxx! inturm i(,n i\ colrur l lgrlr t, comtly wirh rll Ciry a,rd Coutrry
<br />ordiMtr..s Md Strr. ljw! rcld ing r, hu ildinA c.i flcrnin,.ftl icrcl,y,uih{rizc rctr.\. rrrivcs(,rrhisCiryantlCounrtloc.rcruFrtrrh:
<br />firve mnliorcd propcdy lor inslcdi.n prrlo{s
<br />Applicanl o. lEcnl siemnrre
<br />Underground
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER blt?lt! ,.UnE(fr)
<br />Transformers I
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Solfit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />Ivleter Release tal(sl6 ,4,{/411,
<br />Rough
<br />tolt6lty_.4,[AfiU
<br />FINAL to/ts/(g-,ou,4h
<br />Remarks
<br />DATE
<br />Site-Work
<br />Pole Bases
<br />Service lVeter
<br />Notes,Etc.
<br />PolkyNDn$cr: Erfirc\l
<br />I hcrh, rllllnundcr pctralrrolpcrjrry rhar I $r li.cnBl unncr pnvtnnr olCnaprcrl) ((n n.mingwirhSc.ri)n7ll($).lDivNi,rn:l
<br />or rhc Rusincs.trd Profc$iorFCodc- and my liccnsc n in tullLrc!lndclltct
<br />Li..nsc CIus: Li.c.s. N!f,h.i
<br />-
<br />Dxl. (:o m.tn.
<br />L.nd.' ( AddrbY
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