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ELECTRICAL.INSPECTOR RECORD
<br />DATE ID/SIG.COIIIMENTS OWNER BUILDER DELCARATION
<br />I hcreby rffinn unds pcn0lr, oi lcrjury rhar I m excmpr lioD lhe Conr.rron l,iccnsc liw for lhd rolloaing rcrson (sN.7oll5
<br />Bu*inc* ,nl Piofcs\ion Codc): Any Citt or G,unty which r.quncr I Frmir ro c.nsd.t. rl.cr. inprovc. dcmohh or rcp8n ony
<br />nrucrurc. prior ro ns hsuana. aGo regutcs rhc au,licanr lnr sucn Fmir ro filc a \i8ncd {drctu rhnr lr o, shc ii liftn*d pursudnr
<br />b th. polnions ofdE Contm.rors Li.cnai tjw (Chlpto 9, Connnckin8 wirh Scction 7OO0 o, Divhion:l ofrhc Buiinc$ and
<br />Polcsiotrs Codc)or thal hc or shc is eicnpt ltcrciro,n lnd lhe hash lor thc lllcgcd cic rpljon Any violdrinnorselionT0:115 by 0ny
<br />rtplicr ror r ,'.nnir snhjft( rhc {rlicanr t, d .ivil pcnslry ol nor mor. rhM flv. hu Mrcd dollrs l$5u))
<br />-1.
<br />as owrcr of lhe pmrEny. rr my cmplores wirh waBcs .s I hcn eb coq,c.erion. qill do rhe w.a qnd rla strrm s nor
<br />i cndcd or o[.rcd for sak (Se.7Or4. Busiicss and Phacssk,ns Cod.: Th: Contr.ror's Li.cnsc bw des nol qrlly lo in osner ol
<br />rh. pNpcny who huildsor inDn)6lhcmn. tui *ho deF sEh wo* himsclfor hcrsulfor rhmugh his u hcr own.ntl.y.cr.
<br />t'iovidcd lhdr srch i,n|}oBmnr mnor inr..dcd oroficRl for srlc.ll h)m\s. rhc hr ildin3 or in[mvcrmnl ismldwilhinnnc tsr
<br />ofd,rplcrk,n- rhc O*ner Buildcr sill haw rlr l rdcn of povins rhd lr or shc dilmr btrin or i,r{mw rtE I,UIEny for lnc lurl[sof
<br />LisoamrortFi,jnopcny,an.x.lusiv.lyconlrdinewirhli.cnscd.o.trrck,Ntoconstru.trhcpmjccllS(?(r14.Bu\incs
<br />lnd t\ L\\bn Co c thcCotrrrrctoisLiccn\cLr*drcsnotrpplyro!nowncrorpn,p. ywhobuild\.rnnprov.slh.rcon.
<br />rtrd who.orto.Bforsu.hpo,c.hwirhrA,nrrch,ls)liccnsddtufiuinrrorhcCotrtrcttr\Licctr€tjq).
<br />I rd.x.n!rrrtr .r Socri{r .ll & I'C ntrrhn ruynr
<br />DElr OBn.r:
<br />u{]34!trul;1}u[E$ir[&NDI,Q A&Il!.)l
<br />I hcrrbyrffin uidcr l. rlryol plrjrrto c ol rhr follo\tr,! dccllnrntr
<br />!-rtxr Codc. forthcFnnnDrtuc ofrhc sork ror sl,ichrhr ncnnir i\ i\\ocd
<br />I h.ve ann *ill
<br />'uintoin
<br />Bork.rs conrrEtrsaln,n nNumncc. rs rcquncd hy Scct ion .1700 o, rhc llhor (ndc. ror rh. Fiorroft. or
<br />rhc wolk rbr which this p.nnir is hsrn M y workcr' co rp..salion insuroncc cnd., rd rnicy nun .r rc
<br />is issucd.l shrll nor cflrnloyanyl)cson in lnymmlcr( and axrcc rhr if I slnuld tcconf, \ubitl ro ttr
<br />I sMll. ionhwirhomrly *ilh lln,r povnnJns
<br />WARNINCT ,jlilurc to sccurc workcn' .onrEnslrion ovcmsc is unh*lul. md \hall suhjc.r ,n cnDlolbr ro oiDinrl |cnrlri6 lnd
<br />.Nrl finc\ up to ojc hunrleJ rhuuund.h,llar. ($l(,t,.Otx)), in dJi'ion u rhc..s .r.onrlrnstion. d.mscs as flolidcd foi lhc
<br />sn run roTh,,f14
<br />'
<br />ih,.,
<br />,;"",. ?/;l ; :-,;U-t"tzta
<br />/ / DEILA8A.IMA
<br />Ihcrchy'allirnrunJcrFnihyoincturyrh lo ' lrcns&l undcr provision or Ch+rq 9l co'nmncing wir h sfrli,n ?000) of Division l
<br />or rhc ar\im\\!'rd Pmfc\\nnsCodc. ntrd nry li.cnsc n in iullnfcc aNlrll..r
<br />Zo /o.3Lz5/e .-,*<-/d:1@
<br />jjAN$BI](]IIQNIIIDIIG.IGENCI,
<br />I hcrchy rfiinnrl(ldr pcnrhr.r p.rjxr, ih.r rh.r. h d ondtu.ri.n hnding d!.ncy br lhc Flformncc olrhc uork ror which rhh Ismir h
<br />i$!cd (Scc l0S?. Civ. C ).
<br />AIILICANLDECITIBAIIQN
<br />I trN$y ofim under pcnrlty ot pcrjury onc oilhc lollowins dcclararion\
<br />Dcnoliri{)n P.nnilsAsbc{os Norificalion Fcd.fu l RcSuhrnnr (Tnb 40, PM6)
<br />-Rcquircd
<br />t rrcrol Notific.lirxr
<br />I c.nifyrhrrrhc fcd.rdl rcguhrn,di togdnli'rg a$.no\ r.trx,vnl irc norrt1I]li.rhlc N rhi\ 0oid
<br />4"*r :*t .r;r:L'rr;",'r:
<br />fy''vc mmrom,r lm6ry roln.pcr
<br />i.ation a sl.tcthrt lhc ibovc inloirnrtion ilc.rccr l a8.eroconrlywirhall CirytrhJ coutrry
<br />ivcs ofrhi! Ciry lnn Cou.ly b cnrd u
<br />Site-Work
<br />Underoround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Founlains
<br />Signs (monument)
<br />Life Satety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Solfit Rouoh
<br />Ceilings (T-Bar Rouqh)
<br />Ivleter Release
<br />Rough
<br />Service lvleter /lF|NAL 1/3//4 Vh WZ fl /a v
<br />Notes, Bemdrks, Etc.
<br />(2
<br />APPROVALS
<br />Nun$cr:-Expncs:
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