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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNEI BUILDER DELCARATION <br />I h.rcby affiln ud6 F.0hy oi p.rjury rhlr I am cxe.lr fronr rhe Conrtuct,n Li.c.sc L.w tbr rhe n,lhwin! r.asn (Sic 7031 5 <br />Busi.cs and Pr.r.ssion Codc): Any City or Colnly shich ,equtes r p.nnn lo conslruct. ohcr inlrovc. dcmolhh or n',,an an, <br />sructorc. prior to ns hsuarce. llso.eqlirer rhe applicdnr foi so.h !.mn ro filc. sisncd (ar.nrnl ihar hco.shc is liccnsed plNmr / <br />lo rhc pmvisn,ns orrh. Co.t,crocs Liccnscn t2w (Chofler 9. O,mncncing wnh Sccrion 7000 of Division I ollhc Businc$ ind <br />PtufcssionsCodc) orlhar hcorshc h crcnDr rhcrcfronrnd rhc hrqk lor Ihc .llD8cd etemprion AnyvioldlionolScdionT0:ll5hrdt <br />arpli.anr lorrDcrmir slbiersrhc appli.lnllo.civilpcnahyofnolmorerhanlivdhr.drcdJollds($500) <br />l. us os.cr orrhc popcny. or mycmployces wirh wascs as rbdn vn. .onrlc.sar io n- willdo lhc work,rxl lic nrufurc is nol <br />idctrdcd or offcrcd rbr salc (Se.7044. Busincs Md Prorcrsions Code The Conrlucu\ t-i.cns L.w dms nol aldy ro a.6wn.r ol <br />rhe Impeny who b{ilds or inrpmrcs lh.mn. ard who n@s skh wo* hnns.lf or hftlf or rhmugi ht or hft dsn cnployccs. <br />p ro vidcd r har such imptu vc r nk m nor inicndcd or offdcd lo r qle l i howcvcr, r h. buildin3 or i,rYrrov.mnr i soll] wirh i. o.c ]ear <br />of complcrion. $e Own6 Blildd *ill harc lhc bunlcn ol Foving fiar hc or shc dil fr,I build or nq,mrc lhc IreFn, f{r ihc ,)u,F* ol <br />-1. <br />asowner oarhe F)p.ny. dncxclusivclyconrllclins *ilh lienscd cdnrncroN ro con(rucllhc loj€cr (s*. 7t)d4, Businc$ <br />and Pntission Codc: Thc Conlracror's l-i.cns. Ldw d..s not apply ro .n osncr.fprlP.n, *ho builds or improlcs rh.rcon. <br />rnd who conrEch f.r such prelccB wilh 0 conrlctont lienscd p!^@nt b thc conlraclols Liccn* uw). <br />lvotstrli8.s:.cauSENsarlo! <br />DECIASAIION <br />I hcr.hy alltm uder FnahyorlLy]uryonc olrhc lollowin8 dcclararnnN <br />-lhlvctmdwillnuinrdinaCcniltorcotConE"!r{,Sclflisurcrotwo.kcrs <br />conllcnslrion. as !turidcd lor by Scclk,n 3?00orrhc <br />Lahor Codc. lor rhe dromn.c ot lhc sork for which thc Pcrmil is irsucd <br />I hrvc n0d willm0inlain workcra conrpci\drii, nNUrrn..,.s rc!uircd by Sccrioi .lT00 ol rhc l-$.r Codc. f{tr rhc Pjnant .cof <br />lhc wolk rbrwhichlhi! pcmrir is irsucd. Mysorke^ co.V.ns,rion iNuramcuri.raid Flicy nDmbcrarc <br />r I rJt^tlr.l-\ <br />Vi..JCO <br />-l <br />ccnily rhlr ir rhcpcnarn.m.oflhc work lor whichlhis p.rmil t n\utd,I sh,ll not enDloyanrFrs.n inanynmnncr <br />$ rsb h..onr \uhic.r ro lh. workcs compcnsarion lass or Calinmir. .nd ,8rcc lhtrr ill shotrld h.co'ft subjd lo lhe <br />quk.6 conrr..\alion tmvisions ofScclion l70O.irhc hkt Cod..I shdl tunhwith.onDly wirh rhd* flornions <br />WARNINC: I:ailurc ro sccurc workcn .onrpcniarion cov.rngc ir unh*iul, a shrll subi.r rn cnDk,ycr tJ 6i 1iMl [ttrohics lnd <br />ci!i! rincsuDroonchn rcd rh.uqrM dollar ($lu).uxr). in rddilion b rh. co( orcD.rrcnsdion. d nagcs rs liovidcd t rlhe <br />;IdiYJ?:IUIU'I <br />I hcrch, rlfird uMcr rcn,hy oflcrjuylhd I ur liensd under rroviionolChaflcr 9 (onEnci.B with SNtion 7OO0) "rnivi{i.n 1 <br />of rhc Busirc$rnd Pofcsnms Codc. turd myli.c.sc is in tullfncc and cftccr <br />2 <br />I txte: conlrecror <br />CAISIAIJCIIIJNIENDIIG.LCENIJ <br />I hcEby lffifln undcr peMlry of p.rjfiy rhar rhnc is r cotrslrucrion lcnding flsency for rhc pufot,Mncc ollhc u.rk ror which rhh lcmril h <br />tsucd (Sc. 109?, Civ C.). <br />AITLICANLDLCI.AXdIITN <br />I turcrry alilnn undcr !.nally of Dcrjury onc of rh. rollowi.g dalddl ions <br />Dennnion Pernns Asbtsos Nori6calion Fcdcml ReBuhrions (1it|.40. Pan6) <br />_R.qiir.d lrnfi .f Notifcation <br />I .enity lhal thc ledcral rcgulutions ng0rding ssbctus rcmovsl de oor artli.ablc to lhis pmFcr. <br />1l c.nify lh{ I Mv. rcd rhh applkarion and srElc lhor lhd trtx,le irr.nmrion is conccl I asr.c t, .o,nFlv wiln all Cirv ,nd Counlv <br />o i rncdsnDd Srarc li$ rl.r rrgr. $uiklinB .ondrudn)n. rDd nrrriucs.frhk C(y rni C.u.ry k) cnrrr trtxrr <br />ah)vc nrcn(ionctl Impcny nr ily,c..or <br />ADplicnnl or Agenl SiBn{ture <br />9a" <br />JSAY n7 201 ri <br />Site-Work <br />Underground <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Lile Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bondinq / Groundino i UFER <br />Transformers <br />Torqueinq <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouoh) <br />Ceilinqs (Hard & Solfit Rouqh <br />Ceilinqs (T-Bar Rouqh) <br />Ivleter Release <br />Rouqh {/q:t/k \iYt U-;rrn+d-( <br />Service l\/leter <br />FINAL 7/2/f6 9)\6'6 <br />Notes, Remarks, Etc. <br />Pole Bases <br />Sub-Panels <br />Air Conditioners <br />lrn.dc ,m und.rsc-ron F &PC ln' rh'r..hotr. <br />IrnJc''.A'ldr$ <br />- <br />I