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ELECTBICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATIoN
<br />I h.db, rftro unddr p.trrlty of pcrjury lhal I an cxcmpl E m llr Cohx,.r.is Li..n$ kw for lhc followi.! rc,v'n (s.c 70.115
<br />arsnrss a l Profcssn,n Codc): Any Ciry or Coxnr, *hich r.qxncs a lf,rni Io con(ruct. alls. id!rcvc. d.mlith or Epan any
<br />srrudure. Ilr ro ns nsua(.. .lso r.rtuir.r rhe amlicr fo. sucn pcrmit lo lilc a sisEd 4rd.mnr th,( rx or sh€ is liccn*d p!(uant
<br />ro rhc rmvhio.s ol the Conrractols t,iccnEd Llw (Chrylq 9. ConnE.cnr8 qith Scdion 7m0 of oivisi.n I of$c Busincss lnd
<br />PmicsionsCodc)orrhrtn.orsh.is.x.mprrhcr.tommdlhcbnshlorlficalLscnch'np'ion Anyviol,lionofSElhn?0ll5byrny
<br />dpplica.i r.r a pcmir lubl.cls thc opplicunl ro acivilt'cnallroinol mor.lhai 6!. hundrcddollds (3500).
<br />*1. !s o*ncr of thc l,r,rEny, or nry c,ryI,'ytcs *irh wrgcs ,s rhcn st omp€nsrrn,n. sill {h
<br />'rE
<br />wuk irld lhc strElurc is mt
<br />irrcdcd or.ncrcd ior $lc (sd.70,14. Busin.s nnd Profcssioos Codc: Thc Contr.tr's Lic..* Lw does nor applt io rn o*Nr or
<br />rhcpmrrny who builds or inDrcws tlENn. ad who d@s sun m,k hims.lr or hcncll or rhnu8h ht or hq own c.rloyccs.
<br />prolidcd rhai such idrruwmnts e ml inrcM.t .r oflar.t for sL ll ho*cx. rlt l iHinB or inlmrcnr.r is sld wirhin om Fr
<br />oIom{,lcri('n. thcO*mr Buildr will hav. rhc bordcnorlmvi.E thal hc.r slE dil lnild or ir{mw th. pmldy lorrh. pu4x,soa
<br />l..sowmrorrh.pmncny.omcxclusivclyconra.lins*irhliccn\edcont,.nnh.otrnEcllhcprorccllsccT0l4.Bu\i[c$
<br />anl Pioissiotr Cod. thc Conlrlcroi s l,iccor tlw doc\ oor ,!ply !o an orncr ol Imrcrry wio brilds ot imProrcs rhcrsn.
<br />nnd who conrEclrror \kh tn)jcrs wirh a conra.b(s) lkcn{d ruFunr k, rncConrh.ttr s t-ic.nsc L!w)
<br />-l
<br />amcrcr.fl !nd.i S..ln
<br />ratrEall;allfENilflQti
<br />DIILAAAIPN
<br />t hcrchy irfinn o dcr l)cn,lryoftcrjurronc oflhc lolk,$i.E dcch,arions:
<br />-l
<br />har uidwill tuinrain d c.nificoh or Conscnl to Sclal.sure lor $olkcn .\Jf,p.nelion. rs Pmvacd lbtbyScdi.nlTmorrh.
<br />Lohor Codc. l'or lhc p.rfom.cc of thc m* for whhh rhc pdmit is issucd
<br />ZLI havc ond will mainia porkcn codpensrrio. in{rdrc.. as t quiftd ht SNI ion l7m of
<br />'hc
<br />Labor C.d., ror ihc Ptrfomne ol
<br />rhc Nork lorwhkh$n pemil is hsed My wo.kdi oqfnerion insurarcc crin !d poltyn,mt.rdc:
<br />21r356 l
<br />l.tnityrhnr inrhc Erli,rmorcc .l r hc work ftr Nhich rhi\ If, ir h nnrcd.I shrllnol ctrrk,yxny Ptr$n inanyaraflNr
<br />$ !\ro hcsrr $bjc( t, rh. wor*cn .D'npctrsdion lrws olCol onrir md asru. rh r irI \hotrld lrconrc n'hicl r) rlt
<br />worksi.onrp.nsdi,n|n*'iln)nsolSc.riotr:l7tX)oirlttjhorCodc.lshrll-f{,nhsirh.o]try$ithrhoscttr,visioDs
<br />WARNINC: I,rilurc r, \ccurc $.rk.^ conrpcnsrrion $lcngc i\ u hqtul. rtr,l \l[ll suhFr trrr c rtl y( ro crinriml P.trrhhs a d
<br />civil fncs t|] r. onc hundrcd lhot\rid dollars (Sl(Xl,(X)0). irr tdili(in lo rlt c.i orcomNn(.non, dnnrac\ !s rmvid.d fn rhr
<br />Se.rim.ll)76.1 rhc I rhtr ( otl.. i, .'r! rnd rrntr,r)'\ lcr\
<br />D*.51oJfrl th
<br />IEEI,AN{IION
<br />I hcrcby dlrnr uMcr rnllryofpcrjury lhlr I Dm licctrKl und.r rovki.tr olCh{re.9 (connEnciis sirh sNtbn 7000) olDivhion.l
<br />ol rhc Blrims\ and Pmfc$i,,rr Codc. snd
<br />'ny
<br />liccns n in iull nncc rl cffrtr
<br />B lo
<br />c^/lo tlb
<br />CON-IiIBIJ(;IIANIINDINC.AGINCI
<br />Ihcrb,afllrmu cr pcNlryol !.rjurt thd rh.rc i\a.onntu.rnin h ir8a8..cylorih.lcrfomr..corrhcsorllbr*hichrhisF.nirn
<br />i\$.d (s&. .1097. civ c )
<br />AEELICAII.DICI.AMITAN
<br />I h.1$y afinn urdcr pcnolryolperjury ok or rhc rollowing del{alions:
<br />D.mlnion P.mik-Asb.sros Norificlrion Fcdcral Rcslllrionr (TIl. 40. Pan6)
<br />R.quiEd tx'tcr of NolifE thn
<br />I ccnify Ihol lhc lcdcrul rcslhlions rcsodins.rtRsos rcnmvol.rc nol alPlictrhlc ro rhis pmjccl.
<br />IAI ccn iry rhar I hav. rcod rh,\ anrllx0rnn and qorc lhar lh€ abovc infomEiiot h .oEdr I osre lo oml,l, sirh all City and Cou.ty
<br />ordimnccs ann Sl!r. Llsr el,ri.g ro buildin8 conslru€tion, and hcrcbt llrhort bprcsc .tivcsotliisCnylnd Counry ro cmd upon rtr
<br />$orr rhntidrd pml)cny lbr in
<br />Apoli.ml or Ag.nt Si*Mlurc:
<br />c: )tf /laD'l' t)' t v / I l)
<br />7,rri "frlt ,tlo
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Liohl Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm i Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondino / Groundinq / UFER
<br />Translormers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinos (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rouqh)
<br />Rough 5/,s //, t'),€?
<br />Service It/eler
<br />fArFINAL /ts 9xfl,'Et-+\t
<br />Notes, Remarks, Elc
<br />Ivleter Release
<br />'277r-4
<br />5l?.b tuo
<br />q
<br />lrndfl'r Addr.\
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