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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDER DIiLCARATloN
<br />I hcrcby atfirm undcr !.nal,y of pcrjury lhll I ur excnrpl lio'n lhc C.nl,rk,n LenR bw r{r rhc r.ll.wing rcrstr (S.c 70ll ll
<br />Busincas and P,ofcsi,n Codc)r Ant Ciry or Counry shich Eqrncl d l,]rmir b coniru.r. alrcr. nnprovc. demolhh or (Fir xn,'
<br />(rlcrurc. Frior h rrs issuircc, al$ rc{utcs rhc &t'llicrN f.r su.h p.irnit ro filea ri3trcd sr,r.,mnr rhr hcorlhc is lion{d Nrunnr_
<br />tu rhc tr.vi(,r .rrh. Conr..ttr's lj.cnrd Ijs (Chrprci 9, connncming wir[ Scctbn 7u)0 of Division:] oi rhc Busi',cs and
<br />Prcfc*io0sCodc)orrhdthcorshchcxcmplrhcrcio,ndrlrhrrnlbrrhcollcs.dcxenurion.Anyliolalionofsdri.nT0ll.5byuy
<br />!n!licrnr ior ! pcmrn subjcch lhc aplliconr ro 0civiltcnohyofnor nnrc rhln lirc hurdreddolhr l$5(xl)
<br />l. n\ ownr or rhc lmFny. or ry cnlbrlcs wirh w08cs r{ rlrir \.L onpcnsd n'n- riu do lhe work lBl rhc ifl.tur lr mi
<br />inlcntn.rollcrcdlorslc(Sa?O&,Businc$atrdProicrsn'nsCdc:T}cConraci{tr.I-tcn*lrwdmsmt0prlylo oq'ncrof
<br />rlrptuF y who hxild\ or inpmvcs rh.Nn. a who dm\ such sork him\.lfor hcsclfo!thmugh his or hcr o*n crnpktycts.
<br />pmvidcd rhal such imporcrcnh m mr intcndcd o, ofcrcd lor $L lt now$s. thc huiuing or i,rwotftni i\ r,U qirhi. om Ftr
<br />o, con{rhlbn. thc Owmr Suilrcr will haN rhc budcn of pmvitrS rhrl h. or lhc dil rer buiu or in{mvc rhc l,ody f., rlr anrrsc ol
<br />-1.
<br />is owrcr olrhc pnpcny. amq.lusirclyconr,aclinr ril[ ]icc.scn coikrcr* k,..n(tu.rrh. fmtccr lscc. T(}lrl- Bu\if,cs
<br />ai Pnra!\in (-1 cr Thc Cotrt..ror'lLi..trsc l-.wdoc\ ior rtrrlyr' rnosncr oi|rop.rryrvho huildso, tnpn,lcsrhcft.n.
<br />and Rho conrra.rslor \uchpr+ch wirhaCo0hcro(r) li.c!\cnpurunr k,rhcC.ntu.ttr's l-i..nr tj$)
<br />I amcrenmr under Secri.
<br />luJa&:&l:!:!]!lr[NsAllQ!
<br />DECIllf,^IIAN
<br />I hcrchyamr undcr rcnlryol r)djury ok orrh. iull.si,re d(hturionrl
<br />-lhoveofrlwillnrdlin0CcnificaleolConscorroScltlNurclor*orlc6.oopcns,lnnr,dstmvidcdf(tr$yScclion]TmorrhcLho! Codr, iitr lhc !.rfornurcc oilhc work for which thc !.mir h nsucd
<br />rl'. rork 1,tr \rhi.I rhn F]n'ir i\ n\u(l Nl!$,trkdi $i\rioi m\ufun.c.ificr iRlp.li.y nunrIE Oc
<br />P"r*yN,.b",g3.Z6D:i_L
<br />I ccnify rh,r in th. prrfoinurc ofrh. r'ork for whi.h rhi\ prnnir r\ isnrcd. I drllaor entploy nn) p.^on in nny mrincr
<br />v) N ro ticNrnc suijd ro nr sorkcrs co'npctrvrrior h*s ol Cdlihrnir. rnd +rco rh r ifl dmuld h..o.tr subicd lo rhc
<br />*orkc6 compcnqrion pmltnrN ofSc.ri,r:l7lI)ofrhc l;'h, Gxld.l shrll. Lnhwiih.onllly wirh lho* ttovi\n,n\
<br />wARNIN(;T l'aihtrc b scurc lorkcr
<br />civil firs up
<br />'o.trc
<br />hundrcd lhnus!trd
<br />Sccri,'n .llr76 of rh. lrnr Ade. i crcd
<br />,.'", E/4{1s,
<br />co'.pcn\dn,n covcrngc i\ unhsful. rnd \ndl suhl.cr M.nr oltrlo.
<br />,,,,,q.,xxrl. ir l'Llilirion k' rhc.o{ ofconrtL \rrn . dtrtrhgc\
<br />II(:IiLSIJL(!)NIBAIN)tsDll^Brlllg!
<br />I hcrcb, xffirm undcr Fn,lry or ldjury lhar I n r liccnk{ unddr pn,ri.nrn of Chll)lq 9 lconmncins sirh Sccri.n 7Om) ol Diviri.tr I
<br />of lhc Busnr$ lnd Pofc$ioor Codc. ad my ltcnsc t in lull n&r uxi cfid.r
<br />-loz.rz gl
<br />L/t? t rD
<br />qoNElxjJgu0xJ.[NDluli-&o[Nrl
<br />I hcrchy lffirmrndcr Fn,lry orFrjury rhd rhcrc s a.on{d.ti,r lcnrlir8 r8cncy tur rtE Frntrronr orrhc work ror *hkh rhi( Finrir is
<br />hstcd lsa.1r7. Civ C.)t ndca\ N.mc:
<br />-
<br />Lcndcls Addrcs!:
<br />-
<br />AIPJ,ICAILIIEILA8{I]ON
<br />I hsrt y !fim lnncr pcnrh y.t p.rjury oft ofuh. rolk,wn'g d.cl&tr'ionr
<br />llcmririon Pcfl,ils.As$csros Nolificalion Fcdcral Rcs!l,tion\ (Tirl.{1, Prn6)
<br />-Requtcd
<br />Lrrrcr ol Noiiff,nrion
<br />-lenilyrhdIhnrcrcldrhnonpli.alianrnddlrcrhdrhc!h)!ei',nnn,i{
<br />iscoEc.r.Irlrccto.onrdywirh.llCnyudO'unly
<br />oRlinrrcc\nnd Slllc Lresrcl ing in! conntu.rnn,. rRl h.r.hl rdlnrnc 'rrc{finir* oftlr( Ciry0d (nunry n] cfrcr uFn, rh.
<br />ah,!c Nnrioncd lmp.ny ior ir t1rz[r,\pDliu rr nriAorl SiAn r rlL..,k-4Art
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Slandards
<br />S pas, Pool, Fountains
<br />Signs (monument)
<br />Lile Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Translormers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)Ll/ {/,}-1'
<br />Walls (Rouqh)..'' f 4,pe"ft/
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />Meter Release
<br />Rough
<br />Service It/eter
<br />FINAL /r-/r'/c D.5tt/ a),
<br />Notes, Bemarks, Etc
<br />I.crliry rhar rhc rcd.rl aSulnli.ns rc8ding asbcslos rcmv0l rrc .ol 0t'd ic! blc to lhn p8)jNr
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