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ELECTRICAL-INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER BUII,DER DDLCAR"ATION
<br />l hcr.by arfirh und.r ri.nalry or p€rjtry
<br />'har
<br />l an cxcnrl rmnr rhr G'nra.bn Li...sc ltr* ft, thc i{,llowins rcr$n (Sc.7o:ll 5 '
<br />Busincs\ a Pmlasiotr Codc) Any Cny or Condy wnich rcquircs i Fiinir lo co (rucr. 0ltcr. nn,rovc. dcnlohh .r rcIl,r diy
<br />{n,.rur.i rhrlo ils issurnc€.0lso rcquncslh. arpli.rnr ritr sDch Frnir x, file a \isncd {!rcm tlat h.nr shc is liccned pursatrl .
<br />ro rhc lovkions.frhc C.nk.trt l-i..nrcd Lrq (Chryrcr 9. Comnkncnre with Sc.lio. ]ofti of Division I of rhc aunnc* 0nd
<br />Pnnasn,orCodc)orthalhcorshciscrcmprrh.srtufltrndrhchshntrrhcolLscdexcmption.AnyviokrionolSeriotrr03l5Strn)
<br />apllic,nr fir a Fmilruhjccls rhc olplicrnr ro !.ivilp.nalryoan.r norcrlD nvc huidrcrldolla( ($500)
<br />-1.usowtrcrofthc!tu!.ny.(,nrycmrk,yccswilh*!scs0srhctslcco
<br />lrnsnrbn. wiu do rhc work a rh.strstumhmr
<br />inr.ftlLrl or oficrcd ntr st (S.!.Ir,l4, ausiNss dn'i Phrcs\ion\ Codc: l le ft.tacrois l,icen\c lj$ docs not atply ro !. o*ncr oI
<br />lhcfl.ncny wlb buihls or i'nprohs rhcmn. e $lndessu.hs.'khirnsclforhcs.lforrh(,u!hhisorhcrosnchpk,yc.s,
<br />,nJ!id.d rhnr such inpm!.mnk m nor inlcfllcd n ofid.J lor slc ,l how&u, rhc huiuirs or impmlcrEnr t sld I irhio ortr ylrt
<br />.f.o tPlcri{,n, rhc O*ncr lruildcr rillhu( lhc budcnoff,vin! rlBr h. or \hc did tr'r hnild or inpD!. rhc pmpcny hr rhc !uqn{ ol
<br />l..\owturofrhcpoF-ny. Iciclu\iElycofti.rilgIirhti.csdconrmkn\k,..nnrudrhcpn)jcrrlScc7O].r.Bojnc$
<br />rkl thr'c\\bn Codc lhcContra.t.fs l-i.c,rsc l-rw(locs nor Jpt'ly n' aoowNrolprol)cny*ho 6uinkor irnpnr.s rfurcon.
<br />atr qho.ont r\fff\ochFor..rs wir h a Conrmcro(\) liccn{cd!trnurnr krrhc (btrfurof\ l-iccn$Lw)
<br />"\ ,g
<br />DICLAB{IIQN
<br />I h.rchl nllnr undq p.nilryolJdjuryonc ofrlE nJlbwng dcclarrlnrns:
<br />_l h.ve Md sillnmidain s Ccn irf,arc .rc.nrnr ro Sclf lnsurc ior eorkcB'comFns ion.rs p,olidcdInrbyScctionl?0Oofrhc
<br />Lahor Oie. lor rnc lcfornEmc ol rh. *ork fitr r'hich lhc pcnnii i\ nsucd
<br />_l h.vc lnd willnrlintrir workcs co'np.nsrri(,n iisurrtuc- as rcquncd hyScctn,n l?(xjoIlhc L.hor Codc. for thc pcdnmnrnccor
<br />rhc sork t[ *hich lhtD.rnril ir iscucn. Myw.rk.m conp.nsorion insurec. icr a.d rnty numh!, m:
<br />Crric.r_
<br />Pnli(v Nunt{r-Ern'rcs _
<br />-l
<br />ccnily rh.r in rh. I).rronmr& orrhc work for which lhh ncrmir i\ Gsucd. I slull tror cnrploynny |xson i. rny Nnnmr$ Nro hc(rr htccr ro rhc Mtrlcr cotrrpctrsrti.n liqsofCrlinrdir. mda!rucrh,r ilIshoul{t hccom suhJ.rr brh.
<br />wo&c^ .o rpcnsarnrnpnrvi\ion!oisrcrion]Tmolihctihn(odc,lstnll.fonhqirh.onplywirhrho{pnrannr.
<br />WARNINC l,,ilurc lo surc wu.k h conqElsarion covcmsc is unlrwtul. md sh.ll subrccl ,n cmplorr to din .!l |fmhi* and
<br />comFn\r'i.n, doNt.Hs pmvidcd ror rh.
<br />fM't ,
<br />civil fircs uD ro o c hundr.d rh.usrnd dolh( (tlu)
<br />&
<br />Sccrion 3076o{ rhc Ijhtr Codc, ntrcrci ud
<br />T{'{ T )
<br />DICTABAIIQN
<br />I h.icby,0lrm undcr rcnallyolpcrjury lhll I !m lian*lund.r flovi*ion .r Chapr$ 9 (.omftncinB wnh S<rion ?(x]) otDivi{ion.l
<br />of lh€ Buimss and Polcssions Codc, dld my lic..+ h in full roicc und cflirl
<br />iccn\c Numbcr.
<br />-CONiIAISUONIE DINJi.ACENII
<br />I h.rcby "fird undcr rEroll, of pcrury lnal lhcrc iq . co.nd.ri(,. Lnding n-!.fty ror rh. Frfolfu.c of rhc wml for *hi.h rht tsmit is
<br />irsucd (Sa.1097. Civ C.).
<br />l.cnifyrhrrrhc lcdcrJlrcgularionr rcB{dnl8 $hcios rcnxr!Ll arr nornrplicrbh (r rhntnlccr
<br />I.cnrlirh l hxlc ruadrhi\ ln ion ond \rrrc r har rh. .tbvc irLrmrion is con.rr I .gre h cotryly w irh all Ciiy .nd Ci)udy
<br />,,rltrrk.s md Srarc I-n{\ to rri'rg , h ikl ins con(ruction. 0r hclchy rnrhorizc rcprcsctrrilivcs orrhis cily,nd q,unty b cn!cr u,xr rhc
<br />fnna r rioned pn,Fnt ftr eptl$
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />S pas, Pool, Fountains
<br />Signs (monument)
<br />L!l!| Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondin / Groundin / UFER
<br />Sub-Panels
<br />Boof Top Equipment
<br />Facto Wired Unit
<br />Walls (Rough)
<br />Ceilings (Hard & Solfit Rou qh
<br />Ivleter Release
<br />Rough rthelrt-1h,..w>)
<br />Service l\ileter I I \\ (*
<br />FINAL q-r-d21'lTkM//e-9 )
<br />Notes, Remarks Etc.
<br />APPBOVALS
<br />Transformers
<br />Torqueinq
<br />Air Conditioners
<br />Walls (Conduit)
<br />Ceilinos (T-Bar Rouqh)
<br />bnd.' , Add,cs _
<br />APPLICANT TIFCI.ARAT(TN
<br />I li,tby iJlimhder pcnllry oi perjury onc oflhc lollowinS dcldklion\:
<br />Dcmolilion Pcrnils-Asb.slos Notin.alnrn Pcd.ral Rcghr ns (tirl€ 40. Pa'16)
<br />-Req!ncd
<br />L.rrer ol NolirE lhn
<br />I
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