|
ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.(}WNER BU!LDER DDI-CAI'ATION
<br />I hc.chy,mrm undfi pcn0hy oi p.rjury rhit I !m cxempr iiom th! CotrImcro6 Liccnse llw in th. rdk,winS eahn (Sc.?0115
<br />Bu\ioc$ and ftolcsion Codc) An, Cn, or Coxnr, ehich rcqutcr { rm'ir ro co.{dct. .lld. in{'mvc. dcmlish nr rl,rn 5ny
<br />nruft( prid ro iii issudnc., also rcqutcs rhc apFlicmr ror su.h |frnir ro filc 0 sisncd { cnrcnr rhdl lf, or shc G liccnsd pusuanr
<br />ro lhc pmvhions oflh. Contraclors t,icu\cd li* (Chuprer 9. Comncncing wirh sc.rion 7{xD or Divisi{,n I of lhe Blqiners and
<br />PDf.si.or Codc) or thar h.orshc ir crcq)r rhrrcfomand rh. bisk inrlh.lllcScdcrcmnlion AnyviotDlio.ofS.cri.nT0ll5blDny
<br />(fpli.,nt rom p.mil subjccls lhc applicrnl lo rcililpcnrllyold morclhnn fivc huidrcd dolh*{s5(x).
<br />_1. a\ owrcr ol rhc propcar- (r m, c'nphyccr sirh wxgdx ,\ rhcn *,h tunrrcnsnrn r. sill do rhc work md rhc {tulh n
<br />i'ncnddl oronrr.d for srlc (se.70rl. Bnsinc$ nnd ProLssion\ c.dcr Thc Cnnrrrrois Liccn$ Lrw docs nor,pply h anosnfor
<br />rhctnFn! wtu hrildsor n{f,(^!s llEren. and who dm\ suc[ wod hinsclior hcr.ll or rhrough his or hd own cnrdoyccs.
<br />pi(,vidcJ rhd such in{rcrmnrs rrc or inrcnd.{ orolTcrcd fttr\rk ll lx^lcvur, rh. t{iklin8 .r nnpmv.nrm is $ll { irhin onc rr
<br />olcot)lcrinr rlE Osrcr ,luild.r eill htrvc rh. burdcn of t)Ioli.A rh, hd or shc did mr build or irpr.r lhc poFny lor rl- purrb* of
<br />-1.
<br />dsnwncrol rhcrmpcny. aNcxclusivclyconrrading sirh licctr\cd contackns h drrifl.r thc ,r)jd (Scc 704,1, Bu\i,c\r
<br />tr,rl Pnrf.s\ii. Codc Th.CDnrd.toasLicc.scLoBdocsNr6nplrha.owncrofpro!.ny*hohoildsorinrfoitsrhcrcotr.
<br />ond who co racrsforsuchpro]ccls*irhaContlcro(9lkcnscdrursus n, rhccbnt|(1ors Liccnsc l,as).
<br />I amcrcnDr undcr Sccuotr . B. & P.C ltr thn mu-.
<br />Dnle: Osn r:
<br />woRxFRstiiMPFNSAT(tN
<br />D[l!r8.f,ua!
<br />I hcrcby rllim unds pcnolly olp€rjuryoicofrhc nnbNirr dcclnrario.s:
<br />Ihlwu willtrEiNr aCcnikrieofConsctrtloSclf.lnsurcLr*orkc6 n,nrNn\drnnr. us rmvidcdforhySccrionl7l)ooirhc
<br />L.h, Cod.. t r rhd p$fomEn.c of$c *ork for which rh. pd.rir is hsucd.
<br />Ih.r".'.J\rl '.,n r." trnrlc,r \nn'ncr!!rin -rurr1\c.sc.! ion l?0o oi rhc lrbor Codc, lbr Ihc Frfotun c of
<br />.rdici ld polkt Nn'hcr ucrhc sork raruhichihn pcmrir is h{cd Mysnrkcn co
<br />I ccniSrhar in rh. Nnn nrn colrhc }ork ro whichthis Dcnnil n nrued, t \hrll noi .nploy ant pcson in ony unnc,
<br />s, u\b hc$nE uhjcc orhc$orkcf omptn\,l l'*\ol C lilon,ir. xnd iAr.lhil rl'lshoul,lhc..trf, \unt d nirlf,
<br />*orkcn co rcnsiio, I(,rnions ofSccri(D l71X)rhc I-rhtr Codr. I slrrll. lt hr lir..oflJ_ \ ir1, rho{ nrr^,trN
<br />WARNINC l'nilurc ki ecuc Norkcr coDB.n\ i, colsrgc is urlawlul. rtul arll {rbjccr 0n cnrploycr lo ni,ninrl rtrrlti.\ "idh om hunnrcn rh.u\rtrd dnllxr! lSl{x)lXXrJ in rJdnio k, rhc c.n ofco r n ns n . (h'uArs r\ nr)lrdcd nr rhc
<br />n",", - 42 /?^op
<br />IrDCLASAtro!
<br />I rr,.byrlfir uM.rr.nrhyoipcrjuryrhlrI rn licnscd tr.dcr rmvniotrolChrprer I(snnnicncins sirhsccri.n7lx)0) olDivisi ]
<br />of lhc BusirE$md Prefcsn,n\Codc, dyliccnsc h in tullfor(ddcffdr
<br />6/
<br />'/ l!.-.*,
<br />qJAEINULIX}N.LDNDTNC.IGINCI
<br />Ih.'rbyrflnnrri.rlrnrlrrof!.rjuryrhdrhcrcNac.n{fl.ri{ lcndin8 o8cq i.r rhe pcrftrnBn.c ofrh. sork tu which rhis Frnil i\
<br />nsled lss.:rm7- Civ C )t trdcis Na,m:
<br />-APII.ICANLDECI.AEAIION
<br />I hcEby af,id!ndcr petrally or pcrjrry onc orthc r.ll.sing d.clnarions:
<br />Dcmlnion Pcrn rs'Asbcslos Norificarion Fcdcnl Rcsulorions (lirle 40. Pan6)
<br />-R.qui(n
<br />Lctrcr ol Nolifrotion
<br />I c.nilyrh{r lhc ltdcrrlrcS!ldn,n\frgt&lin!,\h.do\rctrnvrltr'c iurrtfli. lcro rIh Pr.icr
<br />l(ai!lhnr Ih*c rc rhi\npfl
<br />onli' n.c\ri{l Sr rr !r1v\ tltul]:e r)
<br />ihovc rrnri{nrcd p'opcny in i'\rccr
<br />icii( ud inrcrhxrrlrc xh rnl, ' ii n\,'(!r I
<br />lu.ltr. rl,, nrc r.pr+ r
<br />rgrcc ro coflPly sirh rllCny.trd Counly
<br />ivds ofrhi\ Cny rnd Counry ro.trlcr ulxin,lE
<br />Appliconl o. Agrnl SiEnnture:L-.,<=-2
<br />f/"2/z €
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile 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 & Soffit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />,^
<br />Rough t0-t*tv Vll#L)
<br />Service lvleter
<br />FINAL 0-23*lg I.wlD
<br />Notes, Remarks, Etc \:/
<br />COMMENTS
<br />Site-Work
<br />Ivleler Release
<br />Lcnds\ Addr.s
<br />-
<br />f-------T------
|