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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER DUILDER DELCAR-ATION
<br />I hcrchy rflirm undcr pc hy .r pcrjury ihar I am cxc'ryr rmm rhc cbnlractor' Liccn€ ti* lbr rhc lolloqing rc,$n (s...7011.5
<br />Burinc* rnd Prorc.sion codc) Any Cily or County which rcquncs a ,mil lo ons!rucr- alrci inFovc. d.lmlish or rcFn ,ny
<br />ercrurc. I,lhr to its hsuarcc. aho rcquircs rhc !p tanr lor slch rErmir lo filc d .isncd iarcmnr rhar tr or shc ( liccnscd NKUlnt
<br />ro rh. I,n,liiions ot lh. Co.kr.ror's Liccnsd ljw (charr.r 9. ComnEncnrs wilh Scctiln ?mO of Diviion .) or $c ausims and
<br />Profcssiotrs Codc) or Ihar hcorshc iscrcm lhcetionsnd Ih€ b.st for rh. alkEcd cicnoion. Anyviol,rio..lSeriotrr0ll.Sbyany
<br />lnplkrnr nn a pcnnir slhj(hrhe lprliclnrro acivilFfulryornot n.rcrhan fiv. hundrcddollors($5(x)).
<br />l. .s osRr rl rhc pmlEdy, or my cmplo)rcs *irh sa8cus rhcn v,h conr!.nsrr i, . will do rh( qo k d thc nBrur! is nni
<br />n crrdcd or oticrcd for $lc ( S.r ?014. Bu\i'E$ and Piof.\irtr Cdlc Th. Contcrois l,i!_cn\c l nw docs nor plly ro an owrcr of
<br />rh. pn,pdy trho hoilds or iq'n'rcr rhcr(n srd *ho dex \uch k)rt hnnsclfor hcrsllor rhmu8h his or hcr!{n cnr,loyccs,
<br />pfl,vi{lcd rhd such nnlro{nrnr\ rc tror ir cNlcd n ottcRt l'or uL. Il: l$$ocr ltE hlitling or iml,R*tm.r i\ sLl siih onc }td
<br />or comphtion. rlE O*ncr Duiiler $ill h,E rlE hrdcn of provins rhar hc o, sh. dll nor btild .. inpoK thc pn,Fny for ltE puqxxc oi
<br />l. rso(ncrofIlr F)fc'r!. n rcx.hNnrly.ontuirE Nirh li.cn\cn l)n'lcd (Scc. r0r4. $u\inc$
<br />alld Pinlssiotr Codc rhc Conrracrois Liccn{c Lawd(r\ nor lpflt
<br />and *ho .unrr.rsfos!.h pmJc.ls wilhaC.nlm.lo(\) I
<br />;',",:9/ik'It
<br />UMr\8!.ll!\
<br />I h.'.hy rflirm un,l.r t^-nrlryol |r{rtury oic ol rhc
<br />-l
<br />h!!c ard sill dai.rain, Ccnifi.rrc ofconscnr b s.lllnsuEf.r workcm ompcnerion,,\ F)vidcd forbyserion l7u)oflhc
<br />LatatrCodc. lbrrhcpcrf{rnEEcof thc work for whkhrh. p.nnil i( hrucd.
<br />-lhav.rndwill
<br />rinr.in worlcs conrFnsrl ion nNUrun c. trs rcquiEd by Sd n n lTrD or rhc ljhor Codc. for Itf, pcdnrromc oI
<br />rhc sork for shich rhhl.rmn is k\uct. My workns- comrcnstrhon inruruncccricr ud poliy.umh.r d.
<br />-l
<br />ccniiy rhnl in lhc pcrtonM'tc ofrhc *ork fd whkh rhi f.rmir is is{rcd. I sh0llnor cmPlo} any IEnon in dny mnncr
<br />s, asro h6,ft {ubicr to rhc workcK compcns,lion laRs olC,li,hmin. md laree rhal ial \hould h.om subid lo tlt
<br />worlcr.onpc.erionrovisionsolSccrbnlT0oofrhetnt r Codc.lshall- lonhwnh comrly wirh rh,e pmvhhns
<br />WARNNG: I'rlurc ro ccuc q.rtcn .rnnn tr\nnnr r xi ri,n' l rtrrlrr.\ rtri
<br />.nil fitrc\ n r. otrc hualr.d rl'ou\anJv,,.,, u,i.,' ,r,J "u,fa. ---",.,",JifuL v\
<br />C0NSIAIJCIIO!.IENDIN:GAGENCI
<br />I hcEbynrfinud.r pc. tofFrjuryth.t lhsc is!mnslruclhtr lcnding aB.ey r. h. p.rfo.nurce olthc*o.k for which rhi$ Fmn is
<br />hsucd lsq. 3097, Civ C )
<br />AfILUANLDECLASAIION
<br />I Im'by !,Im undcr n trllry oincrhry dnc ofrhc f.ll.eii8 dcchhriuns:
<br />D.@lirb6 Pf.rirs Ash.sios Nolification FcdcBl Rcsuhtions (In!e,10. Prn6)
<br />Rcquncd krt.r of Noiiicolion
<br />-l.cdilyrhrr
<br />ft tidcrrl rcsrlxri'rtr {-tddnr! r\hc!o\rc trtrrlrc norinllicrblck, rhis |Jn'J..r
<br />l.cnilyrhrr I h.vc rcrd lhisrpplicrrion mdnrrcrhd t cotr(r.I lgre ro complt wirh dllCnyand C.u.ly
<br />odinr .csand Strlc lirvs rcL ilr8
<br />,hovc f, r i(,mi] fi.pdny iir
<br />.".:':)D/{'"
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Bonding / Groundinq / UFER
<br />Translormers
<br />Torqueino
<br />Sub-Panels
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Rouoh
<br />Ceilinos (T-Bar Rouqh)
<br />Meter Release
<br />Rouoh
<br />Service lvleter .A
<br />FINAL 5r149 |4.w.tw
<br />Notes, Remarks, Etc.
<br />Site-Work
<br />Under Slab / Floor
<br />Air Conditioners
<br />I hcnby amrnundcr Fnollrofpcrjury rhlr I m lie.sj undcr Folirion.r chnpt.r 9 (om.rcins *ith Sc.rio.70m) ofDivisiun l
<br />or Ihc Busiftss and Pmfcssions C.{e. ad m, ltcn$ is i. tull forc urr cfi*!
<br />Liccn\c Clnss
<br />-Li..n{c
<br />Nun$cr
<br />Dere (-onlriclor
<br />II
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