|
ELECTRICAL.INSPECTOR RECORD !
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I herchy afinm under acnrlly ot pcrjurv rnar t cxempr lmnrlhc ConrBcro6 Li.cn<. b* ror rh( roln,wirrS rc.q'n tSEtoll5
<br />Busiocss ond Proic$ion Cde) An, Cily or Co,nry *hich rcqltcs r p.rnir kr cotrsru.l. ,lrcr. irymvc, dcmolish .r EItrt !t,
<br />srtu.rurc. prt,r b ns isuan... nhor.qun s rhc +rli.a for skh F.rn r.lilcan8trcd sakmnt rhat ncorshc is licn\.J prr\unr
<br />ro rh. pmvhions olrlt Conrrlcrols l.i.cnrd ljw (Chaptcr 9- Connnrmin! *irh sc.rnnr ?0(D or Div$ion I oI rhc Busines and
<br />Pmfc*snrn\C.dc)orrhai hrorsh. hcxcmpr rhcrclionrndrhd basi\ fdrhc 0llcgcd cicmlrlion. Any viol.rionolStri,nT0ll.5 hXany
<br />attlicinr iu 0 p.mil suhjccklhc aprlicanrroacivilFnaltyofn r ,mrc rhan fivc hundr dolhr($5m)
<br />l. $ 6w!.rorrh. thlxdy. or f,ycnFloyc.( *nh w.B.s N rlcn rok ompcnsalion- *ill o ltr sort( DDd rlE nftrh 6 no'
<br />irrc cd.rofiercdlorsrlc(Sa.?044.BusircssandProfcssiotrsCo<lc:lhcContado\l,iccnrlrwdft!trol,t'/ylotrnowncroi
<br />rh.fhlEny who bnilrs or inpohr rh.mn. ld wlb dm\ such so* hnnsclf or hcrslf o! rhou8h his or lrcr o*n cmpbyecs,
<br />prolidcd rh0r su.h imoorcmnrs u ior inrcnlcd or oftcr.d ntr sb lt how$cr, th. huildiry or iqrroventnr ir tukl wnhin .ft )td
<br />orompLrbn, rh. o*'ftr Buihs will haE In burdcn oflmvinS lhd rrornEdil nor buiH or inro! rhc In,rdy n rhc IlUr,[*ol
<br />l.isowncrorrhcpmp..lr,dnqclusivclycortrrclirsBilIliccscdco acn'Fr{,con{rucr rhc pn,]..r lscc. 7(l]ll, Busmc$
<br />rnil PDf.ssk,n Codc:'l hc Conr,ctr'i Liccnsc Lrw du.s nor rpplyn, rnuwncrolfropc y who huilds or impn,vcs rtcrcotr.
<br />nnd who conrmck hr such prcjccrr wirh a Conhcro(, licc,sc purulnr t' rhc Conrncroas Lic.tr* tiw)
<br />-lrmcrc
<br />rpl uMcr Sccrion-. B &PC turhi\rorv,n
<br />llate Onmr:
<br />$aa& [rauf[N5a:Il!]l!
<br />DESAAAIIIIN
<br />I hcrcby nlltmundcr lcnrllyolFrjulyom ol rhc nrhqir8 dslanrbn!
<br />I hsvc ud v ill minrrin ! CcnifEalc of Cor*nr ro Sclilnsurc tu *ortcn compcnsarion. !s Inrlided fttr by sNr tun l?00 ol rhe
<br />ttrbor Cdc, r.i rh. r.rfomncc oflhc work lor *hkh rh. r.rmn h issucd
<br />-lhirc und *illmoinroin worter conrFn\rrion insurancc. ar rcqutcd hrsccrn,n]Tmofrhi Lilsr Codc.lir rhcp.riomuNcof
<br />ihc work ft, shichrht Dcnnll is i\\dlrl Myworkc^ dJmFi\ari.n i'run r.. nid ld tricy .un$cr irc:
<br />I c.dify rhar in rhc !ff.rnran.. olthc work for qhi.h rhn r.rnrir is t$cd. I null nor cmnlor sny pc on in rtr! nrtrmr
<br />{' l.ltt .E suhrd ro rhc wintgr .omrcn\al ion lsws otcolitornir. .nd alN
<br />'hnr
<br />irI rtsnld hcorc sh]ccl to rhc
<br />workcm' mDpcn$li prorisions ot Scc(nnr :17(X) of rhc lrhtr Co.lc. I shrll. fiflhsirh .orply wirh rhoc [ovti(,ns .
<br />cilil fincs up b onc htrndrcJ rh.usand d.llrs lSlm.UD). r xtldiinr b rhc coi.f.onrpcn\ ion-funHE.!rs tiovdcd ior rhc
<br />Srdirir 1076.1rhr l-rlrnCod.. crc\ amldktrky-\ l(c\Z{/ t(t I
<br />DES.AAAUON
<br />I hcnby dItrm und$ pcnalty ol pcrjury that I am lisnsal u cr provision oi Chsp!& 9 (c.mm..ing wirh sction 70m) oi Divhion 3
<br />of rh. Busiftse dd Pmfcsions Codc. ot my liccn* ii in tull lor.! rnd cl'fc.l
<br />P ?oo ?<>I
<br />(I}NSTRUCTrcN t FNDING AGENCT
<br />| [cEhy rfirnr undcr Fnallyol pcriury lha[hcrc h a consrrucrioo lcdins sse.cy rur rhc poroflnnn.c orlhc work tbr whichrhh Fmit k
<br />hsucd (Scc 1097. Cir. C ).
<br />tr'"lr' . \rn'
<br />AfIIICANIDECIAAA.IION
<br />! Itrc$y afirm utrd.r l}cnaliy ofFrjury onc of lfic followin8 dsl.rarinns:
<br />D.mlirion P.rnns A$..rx No fica'ion ladcr.l Rc8uld io.s (Titlc 40, Pan6r
<br />Rcquired lxrlcr of t{oliarsrbn
<br />-l
<br />.cnifylhil lhc ltdcrllrcgulari{,ns r.8rdi',s i\hc(o\r.nn,vrl rrc nnr {tli.rbL r.
<br />'rN I'ni..l
<br />I..drfy rhd I hrv. rcad rhN.Itllcrlion orxl nntc thd rh. ah.'c intumurlion i\.otr(l Illgrebco DlysirhrllCiryand Counry
<br />ordthiftcs rtrd Suc Laws rlflin8 ro huildin[ con(ru.rio[ rnd lucby rurhorizc rcprc{nurivcs ofrhn Ciryn*] coumy b cnld upotr lh.
<br />**.'*i$:".-ff2/*;.",C>q/:Li
<br />,.," 1/t/,r
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />as, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Bough)
<br />Ceilings (Hard & Soflit Rouoh
<br />Ceilinqs (T-Bar Rouoh)
<br />Meter Belease
<br />Rouoh
<br />Service lVleter /
<br />FINAL
<br />Notes, Remarks EtC.
<br />,/2/a 7,/,{ -1,U 14,4../I
<br />----+--
|