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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BI]III)ER D}]LCARATION <br />I hotby arfirm under D€nally of pe.ury ttal I an cxmr, tor lh. Co raclo6 Lice6. t w for thc aollowins rcsotr (Sa.?0:11.5 <br />B6i!6s ad Prof6sion Cod.): an, Cny or Co! y which r.luic a Frmn lo coNtDcl. ahq. inprovc. <keolish ot iqtsn int <br />srtucluc, ,trior b ns isuancc. rl$ r.qunB rhc Aplicmr aor such pcmir ro filc a sisncd $aldml rhat h. oi sh. i, lico*d pu6umt <br />lo rh. povnioN of dr Conlr&roa! Licd.d bw (chrrta 9, comn.ftins *nh Sdion ?000 of Divi.ion I oarh. Busins and <br />PrcfNions Codc) or lhor h. or snc i5 ercmpl thsefroD ud thc bsB ror rlr all.g.d exmprion. Ary violalion olscclio. 701 L5 by any <br />aplli.a tor a psnir subjdk lh. applicdt ro a.i!il p.nalt, of not norc tho livc hun&cd dolles {1t00) <br />I. s o$ns olrhc popcny. or ny .oplqEs wirh ras6 6 lh.ir $lc .onpoBlion, $ill do fi. wort ud $c nruclue 6 nol <br />inrqdcd or ollr€d lor sa]c (se 7044, a!si.* &d Proa*ioN Cort : Th. ( ontBclois Lic6F k* do6 .ol t9pl, kr d o$ nd of <br />rlE pmD.ny who builds or impovG thEon. $d who do6 strcfi wrk him.lf o. h.Nlf or lhrourn his or hs oM mpbre6. <br />Drevided thd such imrrsvftils dc d i.nqdcd or ollqld tor slc lt hosdr. th. Lrildi4 or improvdml 6 Fld wirhin o . t@ <br />ofompldiotr th. olmd Buildd wi[ hr!. lh€ hrdo ofprovins thal h€ or stc did mr hild or inprorc $. pmpal, for thc PlqDs of <br />I. 6 osns oflh€ prop6ly. dn .rclusrcly contd.lins with li.d,$d contadou ro coiN'acl <br />' <br />he Plojd (56 7044, BBm.$ <br />asl Phasnn Codc -l'h. Conlracr.. s Lic.Bc Li{ do* nor spplyro aownd olrnopcnywho buildsorinpro\d rhamn. <br />$no conlr k for such pmj€c wirh s Contmclo(, licdsed puuui lo rhc Co.tadois LiccN€ L^v). <br />Iancxc,n und6sNrion .lt. & P.C. fo,lht rcson <br />Drre. Owner <br />v()atrEetlcaluEtlalla! <br />DEQAAAIIO! <br />I ha.by afi.m under Fnrn, oapsjory onc of th. aolk sin3 d(l&arn'c: <br />I hav. dd will m.inl,io a Cc.rificatc or CoEor Io S€la l6uc lor works compmerion, s Fovid.d for by S6lio. 1700 olrne <br />Labor Cod€. tor lhe pslonnocc orlh. art fo. wh,ch rhc pdil i3 dsled, <br />I havc aod w,ll dainrai. work6- conrpcnsarion i6ur.nc., 6 rcqut.d by S.clion 3 Tou ohiE llbor Cod., aor rhc FlomlRe ot <br />rh. *ork aor which rhb p.mil is issued. My worl6 comp.Mlion iNurtrc€ cmir dd poli.y ntrmbd tr <br />PolicyNufrbd: <br />I ccnitrhar in rhc p{fomrcc of rh. $ork for {nich rhi. pdnn b issoed.l shall nor odoy any lNn in any mdnd <br />e 6 to bco6c slbjd lo lh. "!rtd' comp..sslion la*s olcalilomi., and asre lh.l il I shuld bdon suhd lo lhe <br />vork6' .onpoelio. povisioE oasdion ?00 oflhc tlbo. Code I siEll. fonfi\'ilh onply {alh lhoe povisioB.. <br />$ARNINC li.ilre ro surc \orkeG'cornlEnslion co\@!e 's unlaNltrl. dnd shnll $'GDpIL)rcr o dinrinrl rmlr$ rnJ <br />ciril fines up ro oDe htrndred lhousnd dolla* ($100.0001.in addirion 10 rhc cosr Dl damar6 as p'ov'dcd tu rhc <br />inldGrMda otu ysad <br />a- <br />!.M!r!!3IIX\ <br />I h@6y .mnn ondd p@aht o f psjury that I m liccE€d !nd6 Fovision ofch.pld 9 (co@dcing {ilh S..lion ?000) of Division l <br />or lhc lrusin6s 6d Proa6lioG Cod., ad ny 1i.6. L in tull forc. ad .iIel. <br />/ <br />COISIEUCIO!.j,ENI)INCAG.ENqI <br />I hcEby amrn undd penalry of psjury rhar fis. i. a odru(ion kndilts atsmcy tor llE pstomanc. ol lh. \ oik lor which rnis Ftnil is <br />is ril (SLr 1017,Civ (.). <br />AITI,IIANLDICTAf,AIIO! <br />I ndlby rfm lndd paally of lqjury on€ of lfi. tollo" in8 dalrat ionsl <br />Dcmohion Pcmtu A3bdos Noli66rio. Fed(ll Rcgnlario.s (Tirl. 40. Ptr16) <br />._ _Requiicd lnrdof Noi6@lhn <br />I .d it thd rh. f.ddal rcsuLtiotrs r€sddins sb.slos Enolal arc not applicabL lo rhs pmjd <br />I .di! rhar I ha\€ rqd rhis apllicdion md $al.thot rh. ato\c in ion itcordt.I a€Icro.onplyrnhr[ Cnyed Couniy <br />.nlinn.c$ ed srar. Lar s ebri.s Io buildiq consltucrion.authorize rep' Gatalns of rhis Cirt trd <br />abovc n{rn n.! p'lrrry tx iturdion <br />\pflicrnl or '\!rtrr Si!nNrtr 7 <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soffit Rough <br />Ceilings (T-Bar Rough) <br />lvleter Release <br />Rough <br />FINAL 1/%/n 5\,8 <br />Notes, Remarks, Etc <br />Service Meter <br />--D_:.:j4? <br />e