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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNI]R BUILDER DELCARATION
<br />I hcrcby dronr un'lcr pcnilly of pcrjury th l am cxcmol fritrn tl{ Conlr(xF Licc.sc lrw aor rhc rolliJwin8 rca$n (Ss 70ll 5
<br />Busincsr lnd Pftrfc$ion Cdc)r Any Ciry or C.uily which lcitttc\ r Fnir ro con{dcr, .lrcr. inwov.. &rmlnn or EPan an,
<br />ntudurc. prtu ro iis i\\uanc.. dl$ rcqut$ ihr nrplic,m ror such pcrnrir ro fllc. si8ned st(lcmnt lhal ltor shc i! li.cnsd puhulrr
<br />to lhc [ovisio.s oftlE Conrraclols l-iccnscd L1w lchlllcr 9. CommncinE *irh sc.rio. 7000 .f oirision 3 of lhc Businc$ lnd
<br />PmlcssnrnsCode)orrh he orshc n cxemfl rhc,cfr,6 ed rh. hlsis ror rhc alklcd cxcmprion AnyvidllionoaSccrion?0.1l5byany
<br />aplitic,trrtordp.rmirsubiccarhc.mli..nrroacivilp.nakyolnotnDrcrh!fllivchundrcddolh (S5ml
<br />-1.
<br />as oBmr ol rhc ,,,olrnr. or my .n,tl.)e\ $ilh {rsc5 a! rhcn v,h .omt trs'ion. $ ill do th. }dk lnd rhe srturm i\ en
<br />inr.odcd or o flcr.d lor srlc ( S(.7()4?, Bu sincss . nd Pftna$ ion\ C.dc Thc Co racrois l,iccnsc l,rk docr nol +ply tu rn osmr.i
<br />lhc pm,iciy wh) buitds or ir{,re\$ rlmn. ard oho dc qch wIt hinsclf or hcklror tftugh hn or hcr own ctr9loy.cs-
<br />pn,lidcd rhar \uch inlrn*$rnh d *, idcMcd orofic l fDr{h.ll ln,sdrr. ihc ttrildinE or inlt)DwnEnr i\qnd sirhioi. }tr
<br />of.onpldi.n. ih. Oe.cr auilld will htrvc rhc burdcn of foving rhd hc or shc dil nol ttrild or inDmi! rie pmli.ny for rtr puqxM of
<br />_1. xso*ncr.lrhcpn,ncnr. dmu.loriv.ltc.trtd.rin8 wnh li.cnscd.onrrro6lo cotrnrud rhe nmJ..r lS( ?()1,1. Bu{ncs
<br />.M Plolissin C.dc:1hc Conrrocroi\ t,iccnsc l-o* docs nol alplyb rnowmrolpn,!c ywho huildsor nnDrovcs rhctcotr.
<br />and who contn.rs for such pi.F:F sirh a Q)nrncto(n L.ciscd tur$0nr k) r he Conrrrct{ r Lhn\c Li{ )
<br />I xn,crr rjn , n,lcr S..ri,n
<br />thle: ()!ner:
<br />woRKFes;-rntPrr\saltoN
<br />DECLAIA.UAN
<br />I hc,cby rfitnrundcr |rclolly of F.rjrr, oic.rrlt rolk)si.! dc.rarDrionsl
<br />-l
<br />hovclnd willmrinrBi"!CcnifictrrcotConsenr bsclalnsrrt ftn so*cs' .lnrp.trsrtiotr. ir providcd t)rl,yseri,r:lT0oofrhc
<br />Utxr Codc,lor rhc Frlbrrotrc otthc sori tn shich rhc pcrn,ir i\ nsx.d
<br />_lh!!c and willmainrah *orrcu-c.mptns nrn insur,rcc. is r.nuncd b, SL{lion.um oirh.ltrtxx Cod.. tnr rhc P.,{ormrncc oi
<br />rh. *o nranichrhis Fmir is h$cd Myworkc^ .ompcnc ion inntrarcccmicr and policy nlmh.r @:
<br />can,r, AD? To+al So1a"<e
<br />3;.:-o,11o3az1q cA 11u I tf
<br />-lccni$rllllirrhc,)erlornHtr.rolrhc*orkturwhi.hrhi\pcrrnir'\,\{rcd.lshilltrorcmployrnyPcroninmt'nMrrw) r\n, h.onr {rhrc.r t, rlc sorkcn comtctr$rim ln\\ olcrlilirtrin. nnd larec ihJi if I rlnrold b.co,m suhjc.r to rhc
<br />s.rk.^ conr.ns rn !(,visn,trs.fsccri()n:lT0Oolrhcl-.tsrConc.l\h L lnnh*irh.om r sirh rlbr !tuvisi,rns
<br />civil lnrs np lo onc hundrcd lhou\rnd dnlhrs ($lt xrlxx)).l, r,lii,n r, rhc ofcoN{nsrtion. daDnFcs as pn,vnhd nn rhc
<br />s&li(,n 1{r76.1rhc l,,Lr Cdl. inrcrcn,ftlrrt
<br />7 lo l1c
<br />I hcrhy rrlt'n trnJcr pcnnlry of Frjrry r hur I rn lien*l u df ln,vt i of Ch.plcr 9 (.omnrnc in8 wirh Sccri,. 7000) .l Divi\ion .1
<br />ol thc Ausim$ 0nd Pmlcssions Codc. ord n,y licc!* is i. fullrrncc dkrcrr..r
<br />c/o
<br />,,r,. ?/rs/ ta
<br />CONSIBT]CUONIEBIJING.AAENqI
<br />I hcmby.fl_'rnund.r Fn,hyolp.luryrl lltrlc isDoNlrucliotr lcndiry&EcM] ir r hc pcrtortutuc of !h. work iorwhich rhhocrnr n
<br />hsucd(Scc. lO97-Civ. C.)
<br />lrndcis Addrcss:
<br />-
<br />ATILIqNLIIECI.AM.IPN
<br />I tmhy lltian undcr rrcnlhyolpeliuryonc oarhe t,lk si',g J(hrartun\:
<br />Dc bli' io. Pcrmns Asbcqos Nori,icat i{m ,jcdcr0l RcEubtins l l irlc tx). l']rd6r
<br />-Rcquncd
<br />krrcr ol Nolilkrli{n,
<br />_l .crrily fiar th€ fcdcEl Egtrlariom rcgadine {sb.{os ru'mval nc nol trpt'li.o$h ro rht pojd
<br />/ l !.nrI thar I hIc rc irhtr0rDlicot'o rln $arcthrr th.0hvc infolnEtn,n is cotur. I lse ro smrly wirh rll Ciry end Coutrly
<br />ordi inccs rrd Srsr.tiw\ rcl|trnB h huiklii8 yNthr.iTc rcprc{ rrirc orrhi\Ciry d Coutrly lo cnlcr urnr lh.
<br />rhrr trf,nri{,nul lrrt)n.ny rnr
<br />ADplionl or ,\rtnt Siqnntu
<br />Ltl*O ll+n fi ue*eu
<br />?/p lt'
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER t4,1 t9..t.Jq7O
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Faclory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinos (Hard & Soflit Rouqh
<br />Ceilings (T-Bar Rough)
<br />l\4eter Release t4F .B (147
<br />Bough IL I t9 ,u({D
<br />Service lvleter
<br />FINAL ,<'ta.drD
<br />Notes, Remarks, Etc.
<br />WARNINC l;iilurc lo scur. Norkcr conrpctr*,ri,)n.o!crxAr i\ trnhwrul, itrd \hrrl subjc.l nn cnrploycr ro qinri'd l!:trihirs rtrd
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