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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS O\{NI]R BUILDER DELCARATION
<br />I h.r.by afllrm undcr pcnalryorn rjury rhai I mcrcmpt fn,n lhc Conrt los Ltcnrc L,* for
<br />'h.
<br />rollo*i.8 rc.sn (S(?0ll5
<br />Busitrc$ lod Pn,fc$io. Cod.): An, Cily or County Bhth rcquircs n |f.mir to conslrucl- 6116 iopr.w. &nnlish nr rcFir anv
<br />srtocllE, r,hr h ik tsume. olso rciuircs rhc lpdta.l tu flch F.ni ro filc ! \isrcd srareftnr th.l lE or she h liccn{d Pursair
<br />lo lh€ pmvnn,ns of rhe Conracrors Liccnsd t w (ClEplcr 9, Coim.ncin8 wilh S€clioo ?OO0 .r Divhion 3 of llt Susinc* a.d
<br />Ptulcqsbns Codc) or finr hc or slt i\ eicdpr rll.r.ton abd rh. basis lor lhc alk8.d excmPtion. Any violslionolS..lhn ?0ll.5l,v snv
<br />applicrnltototlclmirsubJccrsrhc,tnlicanrroacivilpcnallyotnornFErhdnfivchutrdrcddolltrF(S50o)
<br />-1.
<br />ds os.cr of rhc l(,lEny. {, my cnpn,ies wirh wo8cs rs rhct erc compcn\dn,i. lill d. rh. Ndt nnd rtc srturxn i( mr
<br />irrcDdd {r oricrcd ntr sh (Se.?Ot4. Bnsincs md Pmfesion\ Code:'lhc C.nractors Licc.s Lle docs nol llllll} io an owmt ol
<br />rhe pmFny wh. huilt* or nnprovcs lhemn. ard who dms such wr)r* hnnsclfoi her$lfor rhRrSh his or hcr own cnllor.cs.
<br />Drovidcd lhar such im!.otm.h N nol i, ctrdcd or ollcBd t{, slc li howcvci lltr ttritling o, inl,okm.r it h! rirhir o'E )or
<br />orcon!,lctbn.thcOwncrEuikLrwillhdvcrhcb{nlctrofto!i.8IhalheorshcdidiorLildorir{,mrclhclnFnyforrhcNrlrco,
<br />-l.
<br />iso*ncrolrhc Impdy, a cx.lusivclyconlraclinswilh li.cn\cd coirrrms ro.onsrrucr rhc I'mJc.r (sd.70{4- BuM.{s
<br />a l F\i'f6\i Codc Th.Contracroisl.iccnseLawdo.sfrndPplyrornownctofprcFnyrhohuildsotinpr.rtsrhcrcon.
<br />rnd *ho onrrucF tor \uch ptuFB win a Conrmcll(9 liccn\en pu^uan' ro rhe Conlructois L'icen{ kw)
<br />I mcrcmrr unds Sdh B &PC l.rrhnicr$tr.
<br />Oan.r:
<br />woRl(Flis' (:(tn!PFNSATIoN
<br />DECIAIAIION
<br />I hcrci'y rffii,n undcr FmlryotpcrjuryoE olrhe foll,,wi'rB dehrarnns
<br />IhrvrturlwillntrinloiraCeniicarcolConscnIrosrlf.lNurcr'or*orkc6.onD.6s,lion-!s pmvidcd f(tr by s..lion 3?tx) ol rfic
<br />hbor C.rlc- ar rhc p.rlornuncc oi lhc wo ( for which rh. Frmil ir iesucn
<br />I havc and willmninlrin workcrr.onDcns,rion imurno.c. ns rcqoncd byS..ri.tr 3700otlhc l,r&trci c. fff th. Pcrt{n'mn.t or
<br />rhcqorknnshichrhisFrnririsnsu.d.Myworkasconltctrs.lio.in\orai.c.rEicrnndpolicynlhh.ra.l
<br />Poltry Numbcr:
<br />-
<br />FxPncs.
<br />-
<br />I ccdiiyrhar in lhc FrrornDn.colrhc wort lor shichlhi\ pcrmi r nsucd.l shallnol cq)loyrny Pclson inanvardicr
<br />sr Ls ro hconr sxhJ.rr ro rhc worlos onnpcnurn,n h*s .f C'rlilomi0. ind l8rce rhar if l sh.uld h(.om \uhF ro rlt
<br />sorkc^ co'np.isrrn Frevision\olSccri(,n-lT0Oorrhcbhr(tn,c.lshall-lonhqnh.o l,ly wilh lhoc Pruvi\n'n{
<br />WARNINC Fsilurc ro *.xru workcr coflrEnslrion covrnsd is xrhwiul. rnd shlll suhic.r rn c'nlnrvc! ro dminal |rMhics {nd
<br />.ivil fincs up b om huidrcd lhousrnd dolhn ($lU).lur). in addni.n ro lhc con orconFn\ i.n. ddmllcs ds rtuvirtdl ror rhc
<br />sdbn 10T6olrhc Lrb.r codc. inrcrcsratrd ornntuy \ lcc\
<br />D.lr: ApDlionl:
<br />, rcmsnn colinairtrr=
<br />DEqASAIPN
<br />I hcEhy lmrmudcr lctulry.rpcrjurytnat I om lien$n und.r l,lvBionofch. s 9 (mnrmtidg wilh Satiotr ?000) df Divi'ion :1
<br />or rh. Busimss and Pmfc$ions Cod.. ,d my lt.ns is h tull ,od 3rn cffer
<br />CONS'TRII(: 'IIIN I XNDINC ACENCY
<br />I hercl,y afllfln rndcr trMlryolpcrjuyrha h.to is D .oinru.rt). lcnnins lgdic, li)r rrs rcrtunrnncc ollhc work lnr snich rhis larnir i\
<br />issucd (src loq?. Civ C I
<br />a.tfllsaNtlrEclABArlo!
<br />I trnhy dfmr und.r pcmlr y or p.rjury om of rhc iolloNins dcclDrd nrns:
<br />o.rnnln Pcirnir!Ashe(oi Norificlriun Fcdcral Rc3uhtiotrs (Tillc 40. Pd6)
<br />RL\luicd I rrrcr of Noiifi (ri0,
<br />-l
<br />cdtify rhd rhc r.dcral rc8lllrions cgdrding trt (os rcmvalaE nor applic,blc b lhis Pmiccl
<br />I ccniry lh.l I harc rcsd lhh opplicxlion.rd shtc lh0l lh. olnvc inntr@rio. iscorel. I agre to comply wnh tll Cnvand Counlv
<br />ordina..cs and Srtu t ws rcklins ro huildidg conslrudion. lnd hcrcb, aurhoria ml,.sl rlivcsofth*Cirya.dCounlvtoc.teruponlhc
<br />atolc mnrn Bl tmp.ny lor itrsp€dion I)urrb€i
<br />ADplicani or ABenl SIFmluft:
<br />Site-Work
<br />Underground
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Satety /Low Voltage
<br />Fire Alarm / Dampers
<br />Buildinq
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Air Condilioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinos (Hard & Soflit Rouqh
<br />Ceilinqs (T-Bar Rouqh)
<br />lvleter Release
<br />Rouqh q,/h,'/b 9.ffi tEtu4x
<br />Service [/eter 2el /b s.X€z 'frk,ts
<br />Notes, Remarks, Etc
<br />Pole Bases
<br />Communications Cable
<br />FINAL
<br />Liccnsc Clls:-Li.cnsc NunrlEr:
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<br />lrstE: Conlr.clor
<br />t trd.i( Ad.lE$
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