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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE IDiSIG.COMMENTS OWNER BUII,DER DELCARATloN
<br />I hcrchy offim under pcnalry ol pcrjury rh l mcrcnpr fn,m rhc Cont,.los Liccnse Lrw for lhc ft,llduii! rc$on (Sc70:ll5
<br />Busincs anl P,{lc\sion Co<tc): Any ciry or Coxnry which r.qlncs 0 lcmit lo con(tu r. alrc. intovc. &mlish or EEn lny
<br />sr cru.. pri.,rb ns hsxn.... rle Equncs lhc .pplicmr rbr such tEm iofihasigmdn emnl th0l hcor shc n licen*d puruaor
<br />ro rhc pmvisions ofrhe Conrdcxr\ l"i..nsdd l-,s (Chntrfi 9. Co.nnctri.s Bith Scclion 7Oo0 of Dilkbn I oflhc Busnrcs lnd
<br />Ptrrfcssn,ni Codc) or rhst trorshc ncrcmfl lhcEtom.nd lh. tush iorlhcallcs.deioiprion 4.,viohiionofScction?0:ll5ty"ny
<br />appli.a for0pcrn r subj.rls rhc amli.anr ro !civilpcnlltroi.or rhErhM nvc hundrcd dollss (5500)
<br />-1.
<br />as osturof rh. l,{,Fdy, ofuny cflrlore\ *ilh wn8cs as thcir wk omFn$lion. wJldo rh Bork and l,r $*1@ n mr
<br />iitrcn& orollcrcn lor s e (Se.7o14. Irusims\ and Profc*ions Codc: Tnd Co raclor'sl-iccnscl,owdocsnorJrPIyk,0noRncrol
<br />rh.I'DFny wh' ltuilds or iilr.vs thcmn. id !60 des sEt mrL him*lfot h.r$lror lhn'ugh ht or hcr own.frpbr..*.
<br />nrovid.n rhat uch imporftnk ft mr inrdrLil or onarud ror sh ll ln,w$tr, rlE l{ilding or hpotm h sol! wirhin onc ,rr
<br />or.aftphrion. thc Owmr Buildcr will hore llt hudcn oi FovinB ihd h. or shc did ml build or impmvc thc pmtcrl, rd rht lurrr$ or
<br />-1.
<br />.s owner o, rhc pmpcny, d cxcluii!.ly .oiha.ring *irh li.ctrk{ conlracros ro conndd rtE Iftjttr (s{ 70tl- au cs
<br />ufrl t'r$r6sinr cod.r Thc Conkflols Liccnsc LoB dcs ml apply ro an own.r urrr.p.ny who huilds or impmr.s rh.rcon.
<br />u.d who co E ts lor such rmj(rs wnh d Conracron n lk.nsd pursuanr ro lhc Conl,acloi s Lic.nsd l.rs).
<br />I rmcrcDnr unlcrScdion-. R & I) C f(rrlrisr.rnnl
<br />Dite: ,, O*&r:
<br />WORXl]RS' L](N'PEI\ISATION
<br />DECI.Af,AIII]N
<br />I hcrcby riftrr unrlcr pcnshyofpcrjuryonc orrhc roll'r$ine d.clar0ln,nsl
<br />-l
<br />tav.,J will@i'ndin s crcdificd. oIConsctrt lo Sclf-ltrsur€ io. rorkcrr coq)..sdrion. as rrcvidcd for bySccrion]?fi)orrh.
<br />kbo Codc. lor rhc llcrfomncc or rh. *ork ro. *hich
<br />'hc F.nrir is issucd.
<br />Ihvc,ndwillnlintrnr*orkcrscoflrpctrsltionnNumnce.!\rcqotcdbrS.crn ll00oflhc L\horGnlc. ir rh. ldfurnDRc of
<br />rh. wo* rdwhi.hlhk pcrmir is hsuol. M!wortcG conqEnsarion insuan.. .!ric. ord Flty numhcr ml
<br />':ir*c Tun)
<br />q24t3SEt-1 t*
<br />-l
<br />ccnirrhor nrrtu pcrfoou.ccorrhc work ror whirhrhisFi,nit h issucd.l shlll nor c Dluyitrylcnotr in onyhanrc!
<br />s a\ ti blarm suhi{r ro rhc workss o pcnsnrion h$ nfcllifoniL snd xsnc rhar if| should hec.m \trhicr b rh.
<br />k k.rr smp.ns,r ion povnions of Scclion 3?00 of rhc Llhor Cdlc. I $dll. lon hwilh clmply oirh rho{ Ptuvisbns
<br />WARNINC F0ilurc lo wure *lrkcs comFnsrn,n cov.r4c i\ unhwtul, md \hall \uhi.r an cnlf'loycr ro cnminrl Pcults,nd
<br />cMl fincs uI lo onc hlndrcd rhousa.d dollds ($100.0m). in rddiliotr ro rhc co\r oa co r!..s.rion, danuacs 3s lrovid.d ror rhc
<br />Sr..rion:1074 otrhc ltrtx,(idc, i'n.r{ rd rdoflry\ rcc\
<br />s.zq lt "--0.
<br />!l!!t1-8{Il!r!
<br />I hcrcby 0mnnundcr pemlry or rcrjuiy (hnt I am liensd xndcr provnion olChttrcr 9 (d,nnmncing *irh SNlion 7fi1)) ofDivisn,n -l
<br />ol lh. Busirrcs ond Pmltsioos Gnlc. ad my lk.ns. is in fuil ldR arl cffNt.
<br />P)ta t1q 16
<br />o*" S dl3 ,+6L
<br />raNsIx!.quoxI[NIllNI]-dliENrI
<br />t hcchy trotm undcr rEnrlry of pc.jury rhrr rh.rc i\ r.on{fldi)n hndinS i8ctrcy tr rht P.rhtnrn.c.flhc qork lor $hich thi\ F-nnir is
<br />i\\ucrl (Scc :1097. Cr! (-l
<br />APIUCANLDECLAMIION
<br />I tftby arm undcr ,..alty ol pcrjury om of thc folk'win8 d(LrainN:
<br />Llcrmlirion PcflDirs A3hca.s N.iific ion Fcdcr0l Rc8ulaliotrs (Tillc40. P,n6)
<br />-Rcq!tcd
<br />lluf ot Norifi.aiofl
<br />-l
<br />cc ify rhai rhc fcdcfll Egubl ions mgffding esbcslos rcndol arc @r arpli.abh to rhie 0olc.l.
<br />tsj.cdiry rhd I hlvc rcad this qrpltarion ad slalc rhlr thc lbow informrion t mn.d.I a$e rooopl, wnhallcily snd counly
<br />ordinsnccs md storc llws EhrinS ro building consmdion. dd h.rcbyauthorir rcprcsnlslilcs orrhh Cny and Counlylo cnlcr uPn llt
<br />3h'vc mnrtr,ncd rn,nrny l'{ rnspccrion tur"*s
<br />lppti""nr o.,r*"nrsi**r,* 44 V
<br />r.-,,*,"-u rn"*r, lZirr'[>e t(Y
<br />*,. 5'a't t8
<br />,l4l zu<- lct
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monumenl)
<br />Life Satety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondinq / Groundino / UFER
<br />Translormers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduil)
<br />Walls (Rouqh)
<br />Ceilinos (Hard & Soflit Rouqh
<br />Ceilings (T-Bar Rough)
<br />Ivleter Release
<br />Rough G @ltl ,,(/4E@
<br />t
<br />FINAL 5N?g
<br />Notes, Remarks, Etc
<br />Service lvleter
<br />(t/7lr/ lq
<br />< 2Jt
<br />Lcndcr \ Addr.s
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