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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS ID/SIG.COMMENTS
<br />Site-Work
<br />Underoround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm i Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Faclory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rough)
<br />lvleter Release
<br />Rough
<br />Service lvleter I
<br />FINAL q\r.\t9
<br />^,ltL\(\)Notes, Remarks, Etc
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<br />OWNER BUILDEN DELCARATION
<br />I hcrcb, afiinn undcr pcnolr, ol pcrj!ry rhnr I !m cicmfl fr.rn rhc C{n r0.lon l-i.cns. Ijw r{r rhc rollowi.g r.rson (Se 70:l? 5
<br />Burin.sl and Pior.ssnrn GNdc) Any Cny or Counry which r.quies E Frnrit ro sn(dct. llrcr. inl',mvc. dcmlnh o, rcpln any
<br />srrudurc, lrhr ro irs hsulnce. aho rcquncsrhc amltonr ior such pcmr lo nh a sisncdsrrctu rhd h.orsh. i! ll..n*d pusuanr
<br />to rhc pmlnions orrhc conk..lois Liccnscd tjw (chrrrfi 9. comnclne wilh Scflion ?lxl) ol Oivhion 3 Dt lhc lto\ntrs and
<br />Profcsn,ns Codc) or rhrr lE o. sh. is qcqrr thcrciiom rnd rhc hnsis hr rh. ollcscd cicmprion Any violrrion.rs.di,nT0:11.5 by,try
<br />lpplicant lor ! p€rnrit subjcch rhc upplica h !rivilncnlhy{lnot Inorcrhai nr. hundcdd.ll&s (S50o).
<br />l. a\ os(r of rhc pn,Fny. or ny cn]lbrh\ wirh wrs.( a1 rh.n vnc .o'np.ns,ron. will do rhc wo.k and rhc sInrlurc i\ ml
<br />i cndol or.lTcod for solc (Ss.7()44. Busirr$ and Profcssions Codq Thc Conlra.rors I iccn\.Ils dl)cs nor amly io rn.qrcror
<br />rhc ttuIrny whd h{ild\ or inprows (h.rci.0nd wtk) dNs srch ar* hnnsclfor hcrsltor rhru8h his or hcr own.ntpk,rccs.
<br />p'ovnGd rh,r \uch intDvcnFnh rc rn inbndcd or.rlcftd forsk ll hosdv.r. rhj h{ildirB or imtnNmni Gsoldwirhin"nc )cr
<br />oloq'h(hn. th. ow.cr Buiircr will hovc lhc hudcn ol,,mvin8 rhll hc or sh. dil mr iDih or irwo\c rhc pF,pdr rd rrr Pq$*.f
<br />-1.
<br />rs owrcr .l rhc !opcr), .m cxclusircly conlncrine wirh liccn*d c.nlncro6 h conntu.r rhe proje.r (se 7Ol-1, BunN$
<br />lnd EDf.ssi,n Codc:Thc Conrrsck' s Li.dns. Las docs nor lrrplyt, anosncr orrropciry who build\ or n.lnvcs rh.rcon.
<br />{nd wln c.nh.a ror such pmj(c q,irn a (t,nlmdo(n ltursd punuur ro rhc G)nrDci{n\ Liccnr Li*r.
<br />ul)8tr!&r:.couflNs1llloN
<br />TIIII,AIAIIAN
<br />I hcrch, ainnr undcr lcmliyofFrjuryonc otrh. folloNin8 .lccllra'nns
<br />lhrvemdsrllruirlamnCcdilicat.orCotr*nlk,Scltltrsurclitrxorkcrr$nrrcn\rri{,r-rspnrvidcJf(trhySccrtrlT0Oolrhc
<br />Utxtr C(xlc. lor rhc pt ortuncd of rhc w.* f(r r hkh rh. lf,nnir ir '\\ud
<br />)tt (
<br />-l
<br />tun cxcmpl utrdcr Sccliofl- B. & P.C. for lhh reuson
<br />Drlo O*n.r
<br />I c.nify rh r n, lhc Nrntrne cd ofrh. $o'k lnr whi.h rhi! If,nnir i\ r\{ucd. I sfull tror cnlPloy.ny
<br />I hrvc rtrd willrni rinvo crC comFnsorion insuran.c, ,s Equncd hy Sd n,n :lnr) ol rh. libor Coilc, ror I h. t'(.fornu.c of
<br />rrlt
<br />v' \ t, t .o E subjdr t' !h workcs' conEnso' ion [ws of Crlilirarin. .M !3re rhrr il l should s..onE sbrcd t, rlr
<br />workcn co rp.tr\mor fmvisionc ol sNrion 37m of rlr t,$or Codc. l shrll. ronhNilh co'nply wirh rhos lr,virn)ns
<br />W,\RNIN(;: Irx,ltr( t) \.curc $ork$ .o ,tr \rri,[ cor
<br />.,vil fii.r !n b otrc hrndrrd rhousnM dollar{ (Sl0O.(
<br />l) l.( l. \lt \ llr)N
<br />,rn u c! lcnallyoipcrjury rlul l anr lisnscd under rFvhion olChrprcr 9 (..n n'e *irh Sc.rion T()U]) ofOivnion l
<br />"^rr,li
<br />Cto)y
<br />rt)lSIBIIIIAflAUlll,r!!.i[.L(l
<br />I h.rcby dlir ru .rlE.alryoiNrjuryrharrhcrchaconslnldirkodinatrEcmyaorrhcpcrrormancc
<br />issucdlS.. :ll)97. C iv C )
<br />-l
<br />ccniry rlulrhe lcdc'a I rc-qu lur i{,n\
<br />I ccnifyrhr I lIrcrcxdrhi\ rtpli.ar
<br />okhnrnr.s r Siric lrs\nl: i',B r
<br />rtxnr nrtrrlotrcd pr|r.ny r'or
<br />tpt,li.rnr or,\lcnr \ixnnr
<br />I
<br />DATE
<br />of rh. ausirLssaDd PmLssiorNCodc. ad my liccnsc is i. tu ll r'orcc {xl cltrl
<br />r
<br />L i,,lr,'\ ,lJ,c..
<br />APPt ICANT T)ECLARATI(TN
<br />I hs.bt afllnn Dndcr pcnah! of pcrjury onc ofrh. iollowinS dccln.riotrs
<br />D.nxniion Pcrfrn\ A\bcro\ Norincdion t'cdrrrl R.guhrn,n\ (Tnb40, Pd6r
<br />Rcqrird Ir .r of Norildrir
<br />IR 3
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