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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BT'IT-DEI' DELCARATION
<br />I hcrcby rfirm lndcr F.alr, or p.rjury rhd I am cx.nrrr ftun lhc (hntskn\ l,ic.o\c tj* for rh. follo{in8 ,ca$n (Scc 70ll 5
<br />Busincss Dd Pmft$n,n Culc): Any city or County which rcquilcs ryci,nir io .o (o.r. alrcr. inurovc. &ml(\or tor,t niy
<br />{d.rurc, pritrb ir\ nsu.mc. !l$ rcquncilnc lPplic,nr ri,r so.h!.flnirro 6lc a sisncd srdenrnr rhxr h.drshc ir licctr$d pu6unnl
<br />ro rhc pmlhi.ns of rh. Contr.rocs Liccnscd tiB (Chaflcr 9. ComncncinE wnh s..lbn 7uD ol'Division I oi rhc B!ri'r* .nd
<br />Pnr.ssi. n\ C.d.l or ihd t*orshc k crcnul th.rcf.on bfld rhc hast forrh.alkecd.rcmplbn Any viollrion.rsc.riotr T0ll.5l'ytny
<br />,ppli.anrroratnnilsuhjerslheapplicanlroaciviltuhyolnornbrcrhlnnvchundtcddolldi(35(x)).
<br />-1,
<br />r\ ow.cr ur rhc tlnipcay, (tr ary cmplolecs wilh woscs rs lhcir $lc .. l,cnsd ion. qill do lhc *ork md dc {fl.rm n rFr
<br />imcMcd or ofcrcd for $G ( Sa 7014. Blsincs and Profcsridrr C.dc Thc Conl.lcrois l-i.{n* llw dkl not .plly b an owncr ot
<br />rhc ptr,pcdy ulr, hdilds or irpmt$ rtENo. lod who dms skh w,'l hin\clror hcrsllor rhmuAh hn or h$ own cnTloyccs-
<br />orcvdcd th0rsuch imprcttuna d not inr.ndcil or oficRl tu qh. li h,kvcr, rhc huilhB or imJnovcmnr i v'U wirhin.'k )tr
<br />.r c.mplcrion, rhc owncr Buildcr *ill harc thc lDflicn of p ovnE rhai hc or shc did tror huild or impnw rlE poFdy ror rh. purl,c or
<br />l, rsowncrofr,rc propcny. ! cr.hsiv.lycontn ri,r! wirh li.cnscd cotrlr0cloN lo conntuci Ihc ptujc.r {scc. ?044.llusilct\
<br />snd Pn,r6sirnC.d.: Th. Conli.ctols Liccnsc t,aw docs not apD,y ro osncr or proFny who bu ilds ot nqn,v.s lh.rcotr.
<br />.nd who conrtuts aor such prcFk {irh a cod6.k,(\) ,k.6scd pusu3rt to lhc cirnrrscrois l-i.cn* tiq)
<br />-l
<br />! cxcnrpr undcrSccr
<br />D.ler - OsEi
<br />woRKERS', C(NIPEllSlrl ll)N
<br />D[!!IAA.LIa!
<br />I hcrcby umnn undcr pcelryortfruryorc otlhe lollowin8 dcclaralions:
<br />-l
<br />h!!c and will tuinrdn u c.nific,t of conscnt lo Sclalnsurc lbr wor*cd ompctrsstiotr. as pmvidcd fot by Snl[n lTtD ol lhe
<br />L.bor Cod., for rhc pcrlomee ofrhc wo.t for whkh rh. rnnil is hsucd.
<br />-lhnvc
<br />and willnuinrrid qorkcrJ conrcNalion irruruncc- s\ rcquncdhtSNrionlTlx)ofrhcljnorCod.,forrhcpcrionnin.col
<br />v\t'.J-,rucd. Myworkqa compcnsarion inlonncc.tnicr n Flicynunrbcr u.:ci{(nsl,\l,^=,(3N$\,t-cl t5or &tr-o
<br />-l
<br />ccnify ih3r in rhc p.rfonnrrc ollhc work l'or wnich rhn J--rnrir is i\\kd. I drll nol cmnloy any Pcron in rtr! nrtrNr
<br />$rsbh..unrsubj.crlolhcworkcn'conf.ns.rtntlawsofc.lllirarilrndi8rccrhditl\hooldt.onrsub]ccrrorlt
<br />sork$J conD.nslrion pDri\ i{,tr\ of sNnrn l7m of r hc tjhor C.dc. I \h!ll. t)nh*irh conln, with rhoc F,visbn\
<br />WARNIN(; F,iluB b $.ur. eorkcn omptnsolion colcrasc n unLstul. aM shrll suhjccr an chPk,io ro rnniri Ftrrhi\ rnd
<br />civil fines ut io or hundrcd rhousand dollm (Sl J.Ooo). in addnbn h rhc.os of.omPcnsorion- damg.s as Providcd ftn lhc
<br />,Ji.iv'"Ttlu!
<br />I hcEby alrtm!.der pcmhy or Frjury thlt I om lientd utrdct Fovlsion orChaprcr 9(connEncinE qilh S*rion 7fiD) olDivhion l
<br />or rhc Busincss !trd Protcssions Code. ail tuy licens is in rull foi$ ond ellccr.
<br />V \oet4V<.,
<br />,""ruI l-\altt*fr^
<br />L_ONSI RUC'r(rN I rNnlN(; A(iFNCY
<br />I hircby alfi nund.!Fnahyofpcrju.yrharrh.r.krconsnclhnlcndinsascncylorrhcl.rromtrcofrhesorkfor{hi.hrhhFnniris
<br />isn,L{ (sN llp7. civ. c )
<br />AITUIANLIICI,AIAIITN
<br />I hfr'bl.n nundcr pcnalryofpcru,y o.. orrhe rollowing dsLrolions
<br />Dcmolnion P.rn r.Astcso\ Norilicdrn,n F.dcrtrl RcCuhrbns (Tirlc40. Pon6)
<br />-Rcquircd
<br />Lctrc. oi Norif*di.n
<br />I ccnifyrhd rh fcdcr.l rcBUl!rionr rcglrllnE r\hc\ro\ r.nx'val arc nor dfl,li.ihlch lhisFlccr.K*tI hav. oad thhapplicntn,n Brd \larelh lhc lh,vc i'nnnn,n.n nconccl.I a8reloco6Pl,wirhrllCiryond Counl,
<br />rc l- w\ rclnriraio htrildinsc.n\rn'din c rc]'cscnhrivc\ ofrhk Cir! aid Counry ro ctrrcr uF)n thc
<br />lhove mnr iooed porcny ror insF.rio.pulm*s
<br />ApDli.nnl or A!ml Signolure:
<br />AS't
<br />,N+Y n4lt
<br />Site-Work
<br />Underoround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Torqueino
<br />Sub-Panels
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinos (Hard & Soffit Rouqh
<br />Ceilinqs (T-Bar Rouoh)
<br />It/eter Release
<br />Rouqh 5/tz /tg f:*l Zt;l+ Xl
<br />Service lvleter
<br />FINAL I ,7?-/AJ ')-{s7d -?)
<br />Notes, Remarks, Etc.
<br />Transformers
<br />Air Conditioners \.\.1q
<br />L-"lr' \ AJJ'...
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<br />l-o',-'
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