|
ELECTRICAL.INSPECTOR RECORD
<br />ID/SIG.COMMENTS OWNER BUILDER OOLCARATION
<br />I h.ftby ,trirm uiddr pcnnlly ol pcrju,y th.t I am cxcmpl r'mm thc Gn rmktrs l-i.cns. tjw for rhc rbllowins tcasn lscc 70.11 5
<br />ausincs and Pronssion Codcl: Any Cily or Counly shich requnc\ r ,.rmir io consl ct. .llcr. inrtrovc- demhh .r fttan diy
<br />(fl.ruE. prior ro irs nsuincc. Bho rcquhr rhc atpli.a ror \uch p.rnn ro frlc r siBrEd sr cmnr rhar heor shc h li.cnsd pusuaur
<br />r. rhc lrevisi.ns or lhc Contractols Liccnscd Llw (Chaflcr 9. Comncncin8 snh sc.rn,r 7000 of Dilkion 3 oi rhc Brsints a d
<br />ProicsionsCodc)orlhal heorshe ne&mpr rhctclnnnrnd rh. hrsis for rhcrlkgcdcxcmplion Anyvn arion.fScdionl0:11.5 byany
<br />,pplicam fora pedir \ubjcch rhc dmlicanr ro n.ivilp.mllyofnol morcrhin livc huidr.d dollr^ (S5Ul).
<br />-1.
<br />as ounq ol thc lrropcny, or nry dnlr.ircs wirh wrgcs as rhcir slc comNnsdion. {ill do rhc s.rk nnd lhc alnElurc is rct
<br />inrcftld or oficdd lor $lc ( Se.7044. Busi,rs and Pr oltsions Code fhc C.nlactr's t-ice.\c tjw docs not ll,nly lo !n owmr oi
<br />rhc pN!.ny whohuildsorimpmlcsrhcrotr.ardwhodoe\schworkhnnscllorhcFclforlhronghhtorhcro*nc doy.cs.
<br />pft,vidcd dml su.h inDmrcDEnls m m( inrc edorofl'crcd lbrsnlc.lll how.!$. rhc hrildinA ot inpmvcrNnr is $ld within ic rrT
<br />oiconDlcti4 thc Owmr Buildd wfi hrrc rhc hurdcn oi[ovinB thnl hc or shc did n.r hnild or inll)6r dc tmFny ii]t lhc Puqn$ or
<br />!1llNlXl-.COlrI[NirLllOIIrEct2lllMll)!
<br />I hcrchy rtltfl urdcr rcmlryotpqitrronc ofrhc fdloqing drlrari.ns:
<br />I hrvcrd wi!l tunnain a Ctnific$c of Cotrsctrl lo Scltlnsurc,itr workcrs .onpcnrarion. as Pr.vidcd lhrhySecrn,nlTff).rth.
<br />lih.r Codc, lor rhc lgfdrron.c ol thc wolk fttr which thc pcarnr h issucd.
<br />-lhrlc
<br />nd will maintrin trolkcr' comEns ion insuraNc. !i rcquncd bySccri.n l?(l0 olrhc Lihor Codc, ior rht Frronu..c of
<br />'krurwhrh,hFpcrr.r\i,sucdM)worLers'conrcn.,rion'..d',n,.cd,.rudpoltr)numbcrJc*HzFo*rcl
<br />tfiqLlta s16 t1 52Q
<br />Iccrlirylh inrhclcrioroEnccorrhcworklarwhi.hrhispcflnilkisucd.lshollnorcq)bya.,pc^oninanym ncr
<br />$ a\t, hcconr \xhrc.r ro rhc sorkcr ompcnsarion hws oiC{lilomi( atu]+rc. rhtr itl slmuld licconE subFd t, rhc
<br />workc^..'np.nsalionpovtiotrsofScclionlTOOoflhcLahorC,\tc.lsh,ll.ronhsirhconlplywithlln,Epnvi\i.is..
<br />WARNINC: hilurc t, ECUrc sork .o rpcnsarion corcrnec is unlNrul- anJ shdl suhj..r nn dnllo)q to rinriral Fnrlri:s aid
<br />civil fiics ur ro onc hundEd rhou\,trd dol]ar ($1(x).0(x)). ir addilion lo rhc con danuScs as pruviddd trtr rh.
<br />sc.li(rr 1076o11h. tnl)(tr(itrL. i,r.r.{ a
<br />nr,r-r, Q4
<br />DECIAf,AIION
<br />I hcEby rfirmundcr pemlryofFrjrry rhd I an li.cnscd undo povnionolChoprcr 9 (.un!rcmin8 with Scclion 7m0) ofOivnn,n l
<br />or th. Busincss d &ofcssio.s Codc- and my licene n in tull fi)'e and cftict.
<br />b pnqzb
<br />l{ c-o*". AG C
<br />C9NIiIAIJCIIOIUTNDIIIir!{jEXCI
<br />I hcrcbyrllir undcr Fi,hyorpcijDryrhal th.rc n r con(nrcthn lcndira lgctrcy rin rhr PdlornEncc oithe work n, wh'.h Ihk p.nni n
<br />issucd (Sc. :l(r97.Civ (: ).
<br />AIILICANT0ECITIEAIIaN
<br />I h.rby alIrm utrdcr pcnall y of pcdur, one !l rhe lolkrw ing dccldarions:
<br />D.mlkio. P.flnir$Ashcslos Notificorion Fedcrul Rcgultrrions (Thle 40. Pf6)
<br />-Rcqu
<br />ncd L.trcr of NolirLari..
<br />I.cniryrhar tlrc ltdcml rcEuhtionr rcsrdins rsbcdos rc,rcvnlnrc norrPplic.blc lo rhi\ l]n,jccr
<br />F,.,Y".*l:
<br />rhal lhrvc rcld rhisn0pli.nronrd s.rcrhrl thcilFvc infonnal on is cotrccr lrgrl{ b.ondyNirh rllCiry,id CoDir,
<br />rcp.c{ni.rivcs olrhis Cily rnd Counry k, cnrcr ulx)n rhcklsrJc 1r*s r.lx1i,rs ro huildi'rgro {,u.r
<br />**, S'29 '1f,
<br />1?
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Lighl Standards
<br />Spas, Pool, Founlains
<br />Signs (monumenl)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communrcations Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Translormers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rough)
<br />Ivleter Release
<br />Rough 6lzplrQ -4t44(:t)
<br />FINAL (!/'/(t/17 >D 2n
<br />Notes, Remarks, Etc
<br />APPROVALS DATE
<br />Service [t/eter
<br />I. as owno or lhc pmp.ny. amcxclusirclycontnclins wirh liccnsed cont&ttrsro€nsldcl thc pmrccl (Scc 70.14. au\i.c$
<br />und PnfcishnCode: Thc Cont,.k sLiccns.L{wdocsnor,l)plylo.nowncrorrmrcdyshobnildsoriDJ,rovcsthereon.
<br />and who.o.lr..IslbrsuchnmjcrswiihoConrEcro(9lt.trscdixrsur.lrorhcContractoisLiccnscL!*).
<br />-l
<br />smcxcarpl undcrScdion-, B & P.C. Lrthh rcason
<br />,",", 5. 2Y. lt
<br />tJrdor c Adft$:-
<br />,borc rmnlio.cd prcpcay Io.
<br />I
<br />I
<br />tt
|