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ELECTRICAL-INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER DUILI}ER DELCARATION
<br />I hcrchy.lltm undcr pc.olly of,,erjury lhll I fln cxcnpl l'lonr rhc ConlrlcroF Liccn* Irs r.r rhc lnllowirlS rc.son (5{?0315
<br />Busirr$ and Pdt$ion Codc): An, Ciry or Corir, *hich r.qrirc! , pcnnir r. ..n{,xcr. 0lrcr. in{'rorc. dcm,lnh or Epan 3n,
<br />dtudur.. pri{n b ik i\{rnc., also Equirc\ rhr.ppli.in! rr \u.h n flnn ro filc i siSncd ({rctmnr rhsr hcoi sh. is liccned rursuinr
<br />nr llE rrorhions ol thc Conlracrols Licen*d ltrw lch$rrr 9- Co nftmin8 *irh S.dnr 7lxr0 ol Divhion I orrhc Bosiners and
<br />Pn,acsioi\ Codc) nr rhrr h..rshc hcxcnt rh.rfromanl lhc hnsis l'or rhc rllcscd cxcnrpri{,n Anrvnnnin,nofSNrk,nT0ll5$yiny
<br />rpplicaDl lor a r.rmn suhjclr llE attlicanr lo rcivilpenoltyoinor nrxc rhrn filr hdndtddolln* (S5m)
<br />-l-
<br />owEr ol rh. ,n,axny. or my .mplotrs *nh*dscsrs lhci. lnc conrpc nsi in,, willdo rh.wor*a lh. srmrEc is nor
<br />i, .ntlcd or offcrcd (tr slc (SE 704.1,llusincss md Pn,f.isi.is c(xlc: Th. Conrrodois Lk.n\c tiw docl nor 0rPly ro rn o*B of
<br />rhc pn,rEn, who huilds or in0ovs lllcmn. and wlx dm\ such so* hins.lt or hcscli or ttuou8h hh ot hcr o*n ctnPlorccs.
<br />nrovidcd rhar such improlcc.h m nor i cftltl or oft Nd (r srb lr, tx,rr\E, rhc boihnE or irymvcmnl h q,ld *irhi,' .nc ttJr
<br />or.otrphtion. rhc ownc. Bnillcr will h!rc lh. tud$ of lbvin8 $d h. or shc di1 En hdill or i'nr.\t rhc tmt ny tu lnc ID,InE ol
<br />l.,sosmr olrhc Dnpcny. anc(lusi!.lrcomrding wirh li..n\.d .oNr!.ktrs ro conslrucr rhc lrojccl (S$ 7044. Bu\inc\\
<br />a tt fssion Codc: Thc Conraci(, r Li.ctrsc trw dds mr amly ro M.wncr oltropcnt *ho tuildi or inrpmvcs rhfi.o..
<br />rnd who cotrrfrck lor such pmlcLls qilh tr Gnh.ror(, li.cnscd pusuotrl lo rhc Conlr!.ror r l-kcnsc Lds)
<br />I i cftmor undc' serrctr .ll & PC rar lhnrrJ",n
<br />Dor.r Own.r:
<br />w(|RxERs, CIwrPENis;iidN
<br />DECIASATAN
<br />I hcrchy ainm !nder pcnalry ol pcrju.y o@ orrrr f.lk,wine dNlarlrn,Nl
<br />I havc will nrinroitr o Ccniarclre.r G)n\cor t, s.li:lrur. tu sorkc( conD.nsalion.!s fmvidcd for hySccri{nr 1700 orrl'c
<br />Labd Codc. ior lhc pclformncc of rhc w.r* for *hich lhc I).rmi is nsucd
<br />_l hrvc ,nd *ill m i' xi', work.* comrcn$r ion rn\urumc. N rcquncd hy Sal ion :l7l orrh.ljhitr c.d.. ror rhc pc.lonnancc of
<br />rhc sork ror whi.h rti$lcmir i\ issrL{ Myworktra comFtrsrrnrn insumncc .arirr tuxl Ini.y nunhcr rc:
<br />!1lccn,l) rhrr in rhc ncrforrun(c orlhc worl lor which rhirFrmir ia i\sucd.l \hall nol .hploy lny pcMn inlny n nncr
<br />$ .sh bcom subjccr t,rhe sorkcd .oor.nsai ion hws orcrliturni{.nd oSre rhar iII sblld tcco'ftshlcd ro th.
<br />NorteN conlEnern,n Pmvtion\ of Sdrn,n :l7m.f rhc tibot Cr c.l shrll. forlhwilh onPly *ilh rroscnn,vhions
<br />wARNtN(;: hiturc ro {curc sorkcn conltlcnsdtu corchrc is unh*lul- a shrll sthjccr an cmfblti u diminal Jrurlrics 8trd
<br />.ivil tut\ op r) otrc hoidicd Ihousand dollrn lsl(x).o(x)). ir diiidr to rhc .lconp.n\srt,.. th'mgcs os lrnrvidcd lor rlE
<br />Sr.rirnr.10T6orrhc I2ln L'odc. idcrcn.nd ixoaEy: icc\
<br />/,,.,",qf 4f t E
<br />t)t,t(l.ln\ttrrN
<br />I hcnh! rflnmundcr r.alry of Frjury rhrr I am liansn undcr Eovision orchfrcr 9 (.onnft
<br />of rhc Busii.ssand Pnna\si.nsCodc. atrd mylicctrr t h tull Inre anlclfccr
<br />Sccrirn?(XX))nf Dni(i(,l
<br />C- IO 2'""'tP'8 /-
<br />I ncrcby arfinnundcr pennltyotpcrjuryihar rhcrc is a L\,n{ru.rion bndin! a8cRy ior t[c lcrhnr
<br />,sucd (S.. 1097, Civ C.l
<br />sork lirr (hEh rhi! Iicflnil is
<br />ATIUIjINIDECLAIAIIO!
<br />I tln]r,y,finnulld.r pcnolly oIFrjury onc oflhc folloqin8 dcchr ionr
<br />D.mliiio. Pf.rirs Asb.slos Norificarion t{dcml RcBul ions(Tirlc.t0- Pfi6)
<br />Rcquncd Irlr.r of Norifi .arion
<br />. fl.cdilt
<br />rh, rhc lidctulrc-suIrion\ rsJ'linE I\b.
<br />1l !drrr rlrr I hr\r rcad rhr rlnl'crrLotr mr n.rc rhrr
<br />no\ rcmoul c nor q)plic$lc io lhh rojccl
<br />ordi'itrcc\ rnJ srrrr l-r{\ rLri ! k) huildirg .dnnn'(tr)
<br />*c rronndion i\.omcr lrlrNbco'nflytrirh!llCiryrtrd(-lntr !
<br />hcrc6yrtrrlr'trrcF.\. rrhrcsrnrhlCiryrndCounrybttrrc' uF,rrhL
<br />ahnc n'cnrit 'c(!tFnctrr f.{ in\ncdniI'n4s{\
<br />,rppticcnr or,aeenr Sl*nurure ,t ,\ "
<br />P.rn,i,NnomE,prin,l: lL LjfAA S Nh,.l
<br />,.,", sJ>ilgval r
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilinqs (T-Bar Rouoh)
<br />Meter Release
<br />Rouqh gztl8
<br />Service ltrleler )i_-q,'r,p^/,tq )
<br />FINAL awn I
<br />l I I \--..-
<br />Notes, Remarks, Etc
<br />APPROVALS
<br />PolicyNrnhcr t rqrrc.,
<br />Irndca! Addr.(
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