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ELECTRICAL-INSPECTOR RECOHD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER DUII-T'ER DEI,CARATION
<br />I )rrchy arfirfr uidcr Ptndry {'r Frjry rhd I rn' cx.'np' rn'a, rhc ('.nrrr 'tr' Lictr\c bw lor rhc f.llo*n{ rcien rss.?0.11.5
<br />Buri'r\s Md Prorcssio. Cod.)r Any Ciry or ('ounry rhtrh rcquft\ J tfrnnr rn (nn{rucr. arrcr. imrrn\c. dc'?rl'rh ., Epti! any
<br />snrrurc. priorro ns isnrsncc. rko rcauircs th. rpdi.0.t forru.h Firnil ro filc r si8ncd (lrcmnr rhlr lEor shc i\ liccn\cd pu^u,nr
<br />ro rhe pmvisions of rhc Contarrois l-iccn*d Llw (Chaprcr 9. Conficncni8 *irh S..ti.i 70(X) ol Divhnr :l oflhc B.InEss and
<br />Pmli\snNCod.)orrlulhcorshciscxcmplrhcrcfronrandrhcbdsisfrrrlrallcgcdcrcnution.AnyvnnatiotrotSs.'rint70.rl.tbyEny
<br />apflic!trrli,rr!.nnisubjc.lrthc!ppliconrkr!civilI,cnallyol.orfttrcltunfi!chtrndrodd.lhr\l$51x))
<br />l, 0s owncr or rlD rm,tny. or nry cnrllotccs wnh $ ng.r rs rh.f blc .ImNnqliotr. q'ill .lo lhc wolt lnd lhe srMh il nor
<br />inrc dl or oficrcd ior vlc (Sa.7044. Bu{rc$ and Pml'cs{ions Codc: l he Ornhcrois l,icensc ljw docr nor amly lo,tr owrcror
<br />rhc In,I.dy whol ilds or iqtrowl rh.tun. and who d{6 s!.! k)rl( himrclf or hc*clf or ihouSh his or hcr own c lloyccs.
<br />lrovi'lcd rhil such impNwirrtrh m not inrc.dcd or offcEd fd rrlc lf. hoft\rr. rh. hoihing or inDmrcm h sh Nirhin "m Jm
<br />of co.Dlrion. rhc Owncr Buildd will haw rlE bud.n of lmvi'r8 rhdr hc or sh. did nn h{ild or irr()$ rhc pmtcn, lor rh. purlr)r of
<br />-l.r(otrncroirhclmtxf,y,.ncrclusivcly.otrr,oclir8wirhlicctrs,contrlcx,rrocon\rrucrrhcpxiccr(sc.7{x4,8u{trcs,trd Pn,fLarir Codc:1hc C..tr.roir Liccnsc Law doc\ nor rprlyr) rnowncr ofpn,pc ywho buikl\ or ir.prorcs rhcr.on-anl who onrradr,n. such trcFcls *irh r (-onrra.ro(, liccnsd puFur b rhc Conkd(tr\ t-iccn{ ltrw).
<br />-l
<br />!ncxcnrpt undcr Sdiotr-. B. & P.C. tulhistrn)n
<br />Own.r:
<br />ratsf,[&$:ljouP-t]lsAll0NlElraatrIll!
<br />I h.rrhyJiftn,und.rnrtrrllyof pcrjuryon of rhcftilk)*iD!dcclrrnnnl
<br />-llrvcdxlwillnmi.lrir.Cenifi.rrcol(oflsntroScll.lnsurelbrworken.omtrcnssrion.rs
<br />pn)vidcd fitr bySc.ri.tr 170(roflhc
<br />ht{r C.dc. f{r rh. pcrlortuNc ofrhc *ork for *hkh rhc lcnnn i( nrucd
<br />_l hrv.rnd willmtriruin workcrs conrpcn\rrio. in\mncc- as rcquircd hy Sc.rn,n.l?(n ofrhc l-'bor Codc. ror lhctE lotnuncc.i
<br />rtu worl l;r which rhisFmir is i\lucd M y workcr' comrr\rtin insur mc.rrid nntl |l,ln'ynuNbcr m
<br />I ccnify rhd in rhc pcrfontukc ufrhc sork nr Rhi.h rhN r.nnir n $*ucd. I rh{ll nor cmnloy rny lEron in lny hanncr
<br />$ a\ lo bc..m {'6Fcl ro rhc $orkc6 coo,tEn\arion hws ofcllil'oa,ir- rtrd rgrl{ rhrr if I \k,tld hc.oft rubjc.r o rh.
<br />{orkc6 coarpcnqiion pmvtions ofScdn,n:ITOOol rhe lrhor Codc.l \hdl, f{,nhsirh con{,ly {Ih rhos prlvisions
<br />$ARNIN(l: Frilrr kJ $cutu w.rkcrs .onDcis ri .ovd' !cr.;H;;:1"11".;# " r':1": ::rll.ivil lnrs trf r) onr hr d,.d rhotrsrlld olltrrs (\l(Xr,(Xr,), ltr
<br />sc.ri({ 10760frhc lihtr(iic. ir crcN.fddkrr{
<br />1'z<r(
<br />DECI,AEAUAN
<br />I hcEby amrm undcr !'cnohy of Frjury lhar I am lienrn uadcr rmvisionolChrprg 9(.omftminB wilh sdion 7o)0) olDivision l
<br />or thc Busim*s and Pmr.ssions Codc. ad nry lkcn* ii in full lor.c lrn dTal
<br />*,., 9 - z < - r < *^-**,\Ddz-E4BEe
<br />IANSIBUCIIONIINTINCJJJINCI
<br />I hcrcby ofirn utrd$ Ir.lhy oftErjury rhor lhm is a onslruclhn l€ndiry a8crcy ti,r rhcFrr.rdtrtuc orih. w.rk lor shich lhis pcnnn is
<br />ksucd (Scc. 10S7, Civ. C.)
<br />AITUCANfTECI.AIAIIO!
<br />I try lfmn uMcr Fnahyof pcrjury onc of lh€ followinS dccldolions:
<br />D.mliiio. Pdrons A.h.{ Norin arion F.ddnl Rceuhlnni (Tillc
<br />'U),
<br />PM6)
<br />Rcquind t tr.r ot Ndificdion
<br />I enilydal the fcdcra I rcgu lal ions ESsding 0 shcslos rcnblol a rc nolupplic$lc lo rhi\ Fojecr.
<br />-,lcnirrlharItu\crcadrhit"nnr'*u-"""ro"rz61i),",'n\cinlo,mqrfnnh.gdrIJs's'romnrrodnorccs cnd srorc tjw. rclariM ia huik,ns c"Iv,tucr,16. md hncbyau6,ial6ra$d0rik\ "l rh^ cr
<br />rh.vcnrnr'.'trdnn'p.nlrorh.p".r."n*r.*'( , y' /
<br />npprronr or ngrnr siqdur I t.4 '' <,t ^ Drre:
<br />y wirh.ll Cirylnd Cou.ry
<br />y ald cou.'y io cnrd xpoo rlr
<br />4'25' ,9,
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Buildinq
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilings (Hard & Soffit Bouoh
<br />Ceilings (T-Bar Rough)
<br />Itileter Release
<br />Rough
<br />Service ltileter
<br />FINAL //-tr- /B J).Jtl 'r42)Notes, Bemarks, Elc.
<br />Communications Cable
<br />Air Conditioners Poli.y Numbcr-Extnesr
<br />-
<br />Lcndcis Addc$:
<br />-
<br />--+
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