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ELECTRICAL-INSPECTOR RECORD
<br />ID/SIG.COMMENTSAPPROVALSDATE
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor ll /Bonding / Grounding i UFER -fr)?2 m^bJTransformersHt-//4le
<br />('-,'Torqueino ,.///\-l.r
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Sollit Rouqh
<br />Ceilinqs (T-Bar Rouqh)
<br />Ivleler Release
<br />Rouoh
<br />Service [/eter zrnbl /FINAL -;1@A
<br />Notes, Remarks, Etc.\=--.'
<br />\
<br />(,WNER BUILDER DELCARA]ION
<br />t hcrcby alfinn unds r,cnllry ot rrrjury lh0l I m cxcry)l trom rhc cotrlr0croN l-iansc l-rw ror rhc lol,osins r.ak,n (s.c 70ll5
<br />Alsircs and Pofc*\ion Codc): Any Cil, or Counry whkh r.quncs I lEmil ro 6n{rucr. altcr, iflrPrcvc. dcm.lisi or EI/Ji v
<br />smdue, prktr ro ils isiulncc. rho rcqnid rhc trPttl,cant lor such Fmn ro fiL a .i8ncd $aEmil rh h o. shc n liccnscd Pur rnr
<br />ro lhc Fovisionr .rdE conlmcrols Liccosd ka {ch+rcr 9 comrNncins wirh s.ction idx) ot Dilirion .l ofthc Busincss 8nd
<br />Porcsi.ns Codc) or rh.l hc or shc is.r.mfl rhcrcliomand lnc hasis aor rhc.llcecd cxcnrtion Any vi.htn,nofsatb.70l,5 br.nv
<br />ritlicadforapcmirsubjccr\lhc.rplicanlloacivilpenallyofnormrcth0nfivchundrcdd.iles($llrc)
<br />l.rs oww of lhe pmpcdy, or my cnl olecs wiln srgcsn\rh.i, sL comp.trBri.n. will do rtr wort el lhc{Muc h mr
<br />inrcndcd o!otYcr.d rn$lc (SE ro4,l. Brsitu$.nd Piorc*ions Codc:'l hc G,nra.ktr's Lic.nsc he{loc\ oraPplvrornowncror
<br />rh. nroIEny $h. tuilds or i'qn,vc\ rtf,Brr. lnd who dms sch Mlk hansclf ot icrrll or rhrcueh hi\ or hcr o*n cn lovcc(
<br />Fiovidcd rhlr su.h i,npnNcmnrr m inrcMcd N oflcEd rirr elc. Il h.wcrcL rh. hui[in8 or itrPtuvdBd k skl wirhin onc r*
<br />of.omplcrion. rh. owrc! Build( willhaw rh. blrdfl oIpmvilg ihir h..r sh. did nort Ll or i'I{lturc (hc lmFnv fo. rlt purt-$ of
<br />I. asown$oflhcpmpoly, rm crlusivcly conl,rlins sirh lic.niLal co rrct,,F lo c.intu.r r hc tmjccl (Scc. ?o','1. Burtrc$
<br />ud hDli$bn Coddr Thc Cotrtrscroas l-iccn\c l-aw do.l nor aDlly lo rno*rcr ofrropcrty who tuild\ or impmvcs lhercotr.
<br />rnd vho conlrlcls l'or so.hFqc s qith r Conltacrd, lic.i$d Puru0 lolhcCoitr.ttrrLi.rtr$tr!)
<br />I amcxcmrllnds sc.rn
<br />--B
<br />&Pc lorrhnrcr$n
<br />O*ncr
<br />1l oRKIRS', COlll PENSAl]ON
<br />DLCLABAUI.IN
<br />I hrrcby rflinn uM.r ncndlryolrrjurtotrc orlhc iollowins dcclrarion\:
<br />-l
<br />h.!c and will tun ,in , ccn ic.le ofConsenr k, sclalnsxrc for {orkoi.a,mp.ns0rion.0s Pmvidcd ror bv sdion lTtro olrhc
<br />tjb.r Codc. fo! thc psfornsrc oirhc work lnr uhich lnc lsnn is isEd.
<br />I h0vc rnd sill nuinrain *oikerr coml,.nsario! in\lrntu.. 11 rcquircd b) Sltrion :17(X) ol thc lj6.r Co c f.r rlE I'.rforront of
<br />rhc q'ork nnwhichrhis pctinn is h$cn. Myworlcrs con{f,tr$rion iNunmc.a $tuld,xnicv trunrh.r c:
<br />sD-r- F--J
<br />I ccnifyrh{r in rhc pcrronr'mdofrtu sork lor shichlhis p.i,ntr is hsued. t \hrllnor cmrlovrovF6oD in urvnunn.r
<br />$ !\ ro b.(nft subj(r Io ihc wnrkcr .oflnci\nln,n hqs oiCrliinnis. md +rcc th.r iil shoulJ h.cohr $r$jccr lo rhc
<br />wort.rs corpcns ionpovi\bnsorSccriir:l7lx)olrhc tjh.r C.dc.l shnll ronhsilhco rdy wirh rhos pnvisi.tr\
<br />WARNING ltrihrc Io {cur. wortcrs crNpcm ion crlcrus. is unlnsful. and rhall suhj.cl 0n.nll,loF! ro oin1i,ol lEnohts 'ndcivil fincs uD lo onc hudrcd rh.x\and dollus ISIOO.ooO), in rdd ion lo lhc cosr or$rPcnsarion domaa.r us trnvidcd rorrfie
<br />-scrion 1076 oIrhc hhor C{i.. inlcrcst md trtbrrcy s l'as
<br />? - GJ ( ^pprimn,: ru ;.- A-r,..-
<br />"*i'--qfl##* /
<br />I hcrb, lffirm trndc' r.nrhyorpcriurr rhar I n lic..itri u.dcr pmvision or Ch,Prd 9 (omnEmfus qirh s.cr ion 7il(l)) or Divisbn l
<br />or $c Busim$ .nd lofe$idn4 C{dc, and my lkcn\c k in tull fora ntrd clltcr
<br />A 7"3f,(o
<br />., 2- b-,/R .-,^"*n L/ C/.b,L^/ Rz * -
<br />COI$IBI]CIION.LENDINA.f,GEIgI
<br />I h.r.by aftirm undcr,Enalryolp.rjutyrhrt rhsc k..on(rucrion lcndinS o8cncy for rhc pdfornBncc ollhc sork ror wnich rhis p€dit k
<br />hsued (Sc.. :lI)97. civ. C )
<br />APPLTCANT ITF(]LARATiON
<br />I holr,y allm undcr p.nolty ofp.rxryon. oilhc lollowin8 dcclararioni:
<br />Dcmlition Pcrmirs Astrqlos Noliliclrion f{dcrd I Regu hr iohs aril h 40, P3n6)
<br />-Rcquird
<br />Lcrrcr ol Noril&iotr
<br />I.cnilyrhd thc Licralrcgnhiions Efariina a.bno\ rcmvJ,rc nor 0o,rli.!blc ro rhk pioF<l
<br />I cen iry rhar l tulc md rhis rtplicsrion od shr hrr rhc ah,vc inlonulion t .oftcd I tr8ra lo, @mpl, wnh aI Cn, and Cotrory
<br />hit Cny rnd Counly lo dld utbo if,
<br />o,*, 1- C- / g'/
<br />cc,2
<br />n"-*,, 2 Z a3+;?lz-*t*
<br />L.rl.1a AJJ, ..
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