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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG,COMMENTS OWNER BUI[,DER DELCARAAION
<br />I hcrchy afirm !tutcr ncorlry or r.rjury rhm l , l cxcmpr rbn rhc ConrlElon Licctrsc ln$ r{n rhc lallowiriS rc,son (Scc.?0.11.5
<br />ausinNs and P(ni$ion Coic): Any Cily or Counry shich rcquirc[ Fnnn ro otrindr. lxcr. nnp(,vc. dcnFlnh or rFln Mt
<br />ntuciurc, prhrh irs hsu,n.c. rlso rcqtrncs lhc lPlli.nnl r.r snch li.rmir lo filc! sisned dsrcNm rhar h.orshc n licc.scd Iiu6uant
<br />lo rhc [ovisions ol thc Conracr.is Liccnsd li* (Chrprcr 9. Comm.RinS wnh Scction 7000 of Divnion:] or'h. Busincs: ,nd
<br />ProaesbnsCodc)orrh korlheir.x.n1prrh.turiu'nanilrhcb{islorrh.rllcscdcrcnrrliur Anyvt,lari,nofsNlhiTo:tl thy,:ny
<br />,pplicanrforrl.rnirrubic.Brhcaprli.snltor.ivilpcnollyofnolflsrcrhmfikhrndrcddolltus($5fl))
<br />-1.
<br />!\ owncrofrhc trlFny, rv my.nll'loyccs wirh wrg.r rs rhcn \olc comrnsalion- willdo rlE w.lk,nd thc slmtm is ml
<br />irtcMcd or olT.md ro. $h (Se.7044- Busirc$ ond Pref.sions C.<ic: -l hc G)nr&i{tr\ Li.rns. tjw docs ml ap}ly ro an oNncr ol
<br />rhepmFny sho bnilds or imptuv.. rh.6 r.d wh..ld\su.heorkhinNclforh.rclforrhmughhis.rhcrorncDploycc\.
<br />providcd that such inomwmnls arc (, inrs'rd.tl or oflbtd fff slc ,l lhftru. rhc hoildiry or irynovcnr is s,fil *ithin ..c )t'd
<br />or.o.Dr.ihn. rhc Owrcr auiUd will h.E lh. hnrdcn ol'FmvinS lh.l hc or $c dil mr hli! ur in9rcw lhc ptutdy r'or the !uq.{ of
<br />I.Nowmrolrh.lopcny.rnrcrclusivclyconuaclinss'ilhliccn\cdcoDtrd)^t)con{rucrrhcl)(*cl(Scc 7{X,4, Bt,i"t*
<br />!d ltDrissbn Codc TncContackx'{Lic.ns.LrwiloNnor.pplyrotrtrowncrolpopcn}wh,,l,uild\orln1t'otsrhcrcon.
<br />atrd who .onrrn n, such projcd s rnh i Conrmcknl t lienstl pu^ur h rhc C. k,.ttr\Lrctr*Llwr
<br />-l
<br />Lmercfrfl undcr s.clior
<br />IQAKEBTIAUII;NSA.IIAN
<br />DECIATA.IIO!
<br />I hcr.by allim o dnl).ntrlryofNrjuryonc olthc folkrBirg d€l.r.rnrns
<br />-l
<br />harc md qillnrinrainaCcniicrrcotCon{nr n' scll lnrdrc ntrworkds comlrns[i,)n- !s tovi{lcd id hysc.rion]700olrhc
<br />tih.r Codc. ln, rhc Frl'omncc oi rhc sork for which lhc pcn.ir k i\su.d
<br />l harc oDd *ill nrrn ain aorkcrr .on!*trslrn innrrmc. u{ rL\oircd bySccrion l?(X)orrhc lllitr C(xlc. forrhcF lirnEN.oi
<br />rhc work fin*hichrhi\ p.irnir rs tsucd. Mywork.n (nrFnsrrion iNurrN. catricr a' F,licy xmb.r ml
<br />I rdify rhr in rhc |f,rLrnrnccol lhc *ork i{tr $llich thi\ pcrmir l i\\urd,I \hrll nor c [loy0nylcnon in anymrnn r
<br />\i u\ m hccom {hr.cr ro rhc sorkcn' .o iFn\arion hw\ .r Calironrir. rfrr u!rcc lh ilI shruld b(o'ft \uhjc.r turrt
<br />srnkcrs onrtcnsuri,r p(,vision\orS..ri.r:l?00 ol rhc Lrh, Corlc.l shsll.lonh$irh cannPly wiih ltxJss Pn,visions..
<br />WARNING: F ilurc ro ccurc workcrJ {nrrcnslli(nr (n
<br />.i\il finc\ ut r,.nr hundrc'l rh.tr\rhl d.llirs l$l(x).lrx
<br />,,,,,.i1f1sf ro
<br />Cdc. i cic( rnd altormy \
<br />DECI.ABAIION
<br />I hcrchy amfl.!.der pruxy or p.rjury rh.r I am liftnx.d utrdcr Imvision olChatrs 9(co'nftncing snh sclion 7000) ofDivhion l
<br />of rh. Busi'r$ a'Id Pmf.s{onr Codc. ,Jd fr! li.cn* is in f{ll fom dd clLcl.
<br />r..: /\ , t^1.
<br />"^"'7 / 1 5 19 M {JU*'
<br />coNfrBlsltoNLrNDtlti-atiENcr
<br />I huicbt nlttm und.r Fndhyoipcrjwylhd 'h.rc
<br />is s con(dclion bndin! {cn.y ror lhc lrrfoirMnce oflhc q for shi.h rhis Fflnil ir
<br />is!,cd (Sa. 3097. Cie C )
<br />AITUCANLDECI.AMI]ON
<br />I ffiy lfam undcr pcnahy of pcrjwy o@ ol rhc follo*ing d€l,a' ions
<br />D.trhlirion Pcrmik-Asb.(os Norificlrirtr Fcderal RcBUlarions (Tirlc 40. P!n6)
<br />Rcquned klrcr of Nolifrotion
<br />-l
<br />ccnifyrhr rhc ndcralresuhrion\ r.! di+r\hnosrc mhl& nrr n[t]li.!blc r()lllnF,jccr
<br />l.cnifrrhrr llirr r. rhisrpt,
<br />.'di'rnccsrnd Si rc l-r*\ RhrnEn,
<br />tr rnd stircrhrrrfu rhorc irlonndion
<br />ot&vc mDrioncn nm|cny n,
<br />Applicnnt o. AA..l SiEtrhnr
<br />aErN r, omnly sih ill aliry Jnd GunD
<br />Nc\ rrhrc y,nd coulftyt. cntc!u},n ltE
<br />^," ?LilE-
<br />Site-Work
<br />Underoround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Translormers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipmenl
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)il- t-fit - ))e )ef(,-t {)
<br />Ceilinqs (Hard & Solfit Rouqh
<br />Ceilings (T-Bar Rouoh)//..8-r9.DJt+.t iv)
<br />[,4eter Release
<br />Rouoh
<br />Service lVleter
<br />FINAL /2-?-/e J)asdz ,ad
<br />Notes, Remarks, Etc.
<br />LcnJci' Add c*:
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