|
ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE OWNI]R BUILDTR DELCATATION
<br />I h.rcby {fllrn uftLr Dcnnlly ()fl'criury that I am cxcNnl ton lhc C.nrrucron l-i..n.c tf,w r.r
<br />'h.
<br />iolloNin8,casn 1Sc.70.ll5
<br />Businc$ md Prolc$ion Culc): Ary Ciry or counrt whi.I icquir.\ r Fnnir lo con(ruct. {llc,. inDmvc. rhtu kh ,tr rjaln Jny
<br />inclurc, rirk, irs h\un..c. rko nquncslhc llPflic.nl for suchFnnir to filca \isncd {d.tunr rhur h.or shc is liccnscd Pumuinl
<br />to rh. povtione oi rhc ConrGrols Liccnsed li (Chlplc. 9, Comtuncins unh Sc.rion 7m0 ol Divhho .l .f rh. Btr(incs ..d
<br />Prorissionl Codc) or lhat hcorshe t crctrlPr ih.rcfromlnd rhc hrst l;rrhc.llcS.dcrcmprion AnyviolalionofS.crionT0llJl'yiny
<br />applicrnr ln! a pcrn,il srhjccrrrhc lprli.rm ro r.ivilpcndhyornor morc rhin lirc hundr.ddolla rs5mr
<br />_l- x\ orncrof rhe poircny. rtr rycrploy.rs wilh wrgcsasrh.n inc c.nrFns!! io n, willdo rlE worl ud rhc {fl.rm i!ftn
<br />inrcndcd or offcrd ror eh (Sc.7(,'l.r- Busirc$ lnd Pmn\sions Cdc Thc Cohtrrcktr s t.i..Nc hw d.cs tror qrtly h lno*tur or
<br />rhc ljft,pd! wlD hikls or i'qrDlcs rhcNn. Md wh. dms su.h wo* hiNcll or hcrrll or rhmugh [n or hcr .wn cntnloyccs.
<br />nrovidcd rhrl slch imtnoEmnrs m nor inrcndcn or onid f(tr saE li hrwcvcr, rlt hx TdinB or in{svcrrc k sld *irhin om )qr
<br />oi conDhtiotr. rtE Owrcr Buildq will haE rhc h{rlcn ot Imyi,{ lhd h. or shc dil nor buikl or i.'pn'vd $c lmFny f.tr lhc fi,ryM ol
<br />-1.
<br />!sowmrollhe oopcrry- !mcrch\iv.ly.onti.tin8 wirh lic..s.d .o nha.toN ro con(rucl lhc prorccr lscc ?0r{, Bnsrc$
<br />.nl Pn,fssirn Codcr Thc Conta.tors Li.cnse Law dcs nol.Drly lo an osncr.fpn,p.ny wh() hrilds or inDmve\ lhcreotr.
<br />lnd Nno conrrlcrslor sLch l'oira wilh 0 conrdo(s) li.cnicn puruuN hrhcConrmcrals l,iccn* Lxu)
<br />I amcxcnr u er Scclion-
<br />Da(c: Ovner:
<br />woR(Erls' coltPENSATxrN
<br />DECLANAIIQ!
<br />I hcrchy amrm undcr !.nohyolp.rjuryore of rhc f{nbwine dcclarurioni
<br />I hrvc dt will minrri. a Ccnificarc oiCon{nl'o Self lnsurc for workes ..n\rnsal ion- .s pr.vidcd fitr hy Sccrn,n 1700 orrhc
<br />Ilhir codc, r.i rh. lclformtrncc ofih. *ork ior ghicn lhc pcnnil is hsucd
<br />I havc a*l wilt 'nrinrrid *orkc$.om|xn{tnr irsu ncc. ns rcqutcd hy Srrn,n l7(X)ofrhc bbor Codc. Io. rh. pcrforrome ol
<br />dricr drd [ni.t nurbcr ec]I'cn i n tsd M' wor[c6 (.DBnsrri.n insun'n..
<br />P.ri.yN*,,r*,, Dv$\l \.\.
<br />_l ccnilirhar in rhc pcrnrtu,f,.or'hc sor* ror whi.h'hi( pcnnn n nsucd.l xhall nor cmrloyrnyr(rv,r irr ttrymlnnct
<br />$ $t' bc.om subjer ro thc work.r' compcns ion h*of Csliaorni", xid agrcc rhdr irl should bcconE subjcd ioih.
<br />*.rkd I c.nw.sahon ,mvhioos of Sccr ion :l7lro ol thc I ibr Aiq I shdl rrrhwirh onply with rhot pnvtioh
<br />WARNINC: Failurc ro scud *o&.*'mnt nqrt,n.\,v.agc is unhwtul. d shall su h 5 sflria< k, dinnnrl |f,Mlli.\ lnd
<br />civil firc\ up lo onc hun&cd rh.rutrd dollrr (Sl00.U)0). in ddilion lo rhc ior, datu8cs a\ pmv cd t)r rhc
<br />r)1.{ I \lr \ llr )\
<br />I hcrhy alfirn undcr F.,hy ol lcrjury lhd I m liensd undcr Imvhioi orChafl.r 9 (ommRing wirh Seclion'71n0) orDivisi.n l
<br />of rhc Bo\incs dd PFrcsions cod., 0.d my li.cne is i. full fora md cfis'
<br />t0O't nt ro't
<br />'"'"1Sg-${LJJid"*'-"* F^[-*a
<br />colsrBuqrloN.liElDllclc[lcr
<br />Iheftbylfrrm!od.rp€nalryofFiuryrh rhsc is { conslruclion tndins lscky ,or lh€ Frfo.Ms of tlE m ( for ehi.h thh Fmir is
<br />is{rcd rscc .l0i)7. Civ C L
<br />ATEITCANLDESAMIIO!
<br />I hmny ofim undcr F.alr, of p€rjury onc or lhc rotlowi.B dccLtralions:
<br />Dcnrlnion PcirnniAsbcsros Notificarion Fed.ral REBul,rions (Title 40. Pd6)
<br />-Rcquncd
<br />L.ucrof Notifi qrion
<br />Sccniryrhor I hNc r rhnDppli.d
<br />ordin0rccs ind Sn'lc h*a Blnriir bhu
<br />rbovc trr.tioncd lmpcrty lor ir\Eclion
<br />io,rnd (ncn rrlr.rh,!. dr,n xrrj i r\
<br />,\ppliGnt or A*rnl Sign ure A^
<br />nsre ro conply wilh,u Cnyand Counr,
<br />ivcs oarhil Cilymd Co,nryro cntcr upon lhc
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Salety /Low Voltaqe
<br />Fire Alarm i Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Torqueino
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rouqh)
<br />Ivleter Release
<br />Rough r/,{y's 5A ,-E
<br />Service lt/eter
<br />FINAL vsvt* 9t fat zflf8,I
<br />Notes, Remarks, Etc.
<br />ID/SIG.COMMENTS
<br />Transformers
<br />Sub-Panels
<br />Sc.rion :10?6olrhc htnrG'dc, inr.rc{ dnd .nry s Lcs
<br />AUrt3lol$
<br />1..'iil.yrhrrrhc lidrnl rcSularion( rcEddirA r{hcn.\ rcnFvil0E nol rDJ,licrhh h rhr FJj..r
<br />l)!le:,l
<br />I
<br />----l---
|