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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS oWNER BUI[,DER I}DI,CARATION
<br />I k.cb, rm undcr I]cnolly of pcrjury rhat I m cxcnlnr fmm lhc Co.tacroN Liense Liw for lh. follo{in8 Ea$n (S.c 7031 5
<br />Busi.css anl Pr.tc$ion C'ftlDlr Any Ciry .r Cou.ry which rqutcs d lrcrorir ro c.n(dcr. alrs, i.rlrclr. rhtrkrirh 'tr rulan sny
<br />srruclulc. t rrlo ns ks,omc. ols.cquncs rhc aF lic.m ror su.h pcirnt h iilc r signcd srdrcmnl
<br />'har
<br />tEor shc n li.cnsd purunnr
<br />ro rh. F)vhn nq orrh. Co.rrrcktr\ Liccnscd ljs (Chlnrcr 9. Con'mncins wirh Sccrt'n 7ofir of Oilhbn I orrhs 8!rincs\ nnd
<br />Pn,fc*n,rs codc) or lh,r h.or{hc i\ .x.mrr rh.rcfinm a.d rheh tnrrhcallcscdcxcotti{,n A.rviolaii.iurScclbn?0.rl.5bydny
<br />aptlicrnr br! lf,nit suhlcck rhc rDpli.an( b a.ivilpcnnky.fnor dtrcrhrtr lilc hundnddollns (5500)
<br />I. rs osncr of rh! rorEdy. or ny eryl{,ras sirh w!8e\ rs th. t snc onlpcnlllion. *illdi' rhc {o[t snd rhc { 1h n 'iIinrc cn orofltrcd lor $lc (SN.7IX4. Ausincssnrd PmL$i,,nsCodcr Thc c()nrrrofs Li.cns tiw docs nor amly n) ar owncr ol
<br />rhc prur.ny who t ikls or impn&s rh.6n, nnd sho d{n skh m,rh hinrclf or hrrscl, or rhn)lth his or hcr oNn cnDlo}ccs.
<br />nDvid.d rhrhu.h impmvcnrnlsoE mr inrc,nhnor.fiarcd lor s.L lI howcq. rlEhoildinsor inpmEnrnl h s,kl $irhi', orc ,tr
<br />of conlFkrio.. rhc Osmr BuiH.r will hre rh. hurd.n of !tr,ling rilr l_f, u \ht dil Bn hild or nrqtr.lr rhc n6Fiy ft, lhc NrF{ of
<br />-1.
<br />!sowncr oirhc nmFny. ior crclusivclyconlradir8 wirh li.cn{d cont.crorto con(rucr rh. lrojccr (S(. 7(}4,1. Bu.incs
<br />,nd PhLski Codc: Thc Contncrois Lic.n\e Lr* docs not lppl, k,3nosndr olpruI,.ny whr) builds or inprorcs rhcrcon.
<br />and *ho o rocts lor such pmjccls eith ! Conlrocrorls) liccnq'd pusuunr ro thc Conrrffkr\ Liccns Lrv)
<br />-l
<br />mre.cnrDt undcr Sslion-. B & PC. for rhis rcason
<br />Dal.: Oroer:
<br />woRxFx.slroMlrNsATroN
<br />lECllaArIA!
<br />I h.rcby nnird u.dri pcmlryofFrjury.nc.rrh. followin8 d(loErion\:
<br />-l
<br />luvc andwill nmintiitr iCcnificurcofConscnt to Sclllnsurc lor woltc( compcnsation. !s pmvidcd fo! l,ySdrn,i:1700 orrhc
<br />tjhor Codc, for (hc pe.lo.mn.c ol lhc srt for *hich rh. pdnir is k\ucd.
<br />I hrvc rtrd silLn i'nri', wnkcrr .o'nmnsrl i,nl rs rcquircd hy S(I i,)n :l7lx) oi ihr l ihor CoJ., fd rhc lirtJnn {c ol
<br />qlion innmncc c!tricr !d policy nunftc.rc.rhc s.rk ln shichrhi\ pcnnii is istud Mysorkcd co
<br />I ccnilyrhar in rhc p.ri.nnrn.c of rhc q.rk whi.hrhis p.rnit is iskd.l shrll n.l cnrtloyonyrcnotr in anynrnm!
<br />$ sro bcconE suhrc.l ro rhc *ortcr conrpcnurion lo$soicariior.ia. an! asrcc lh if l slNuld t oEsul,j6riorht
<br />workc.( comprnsalion prrisn,ns or Scclion l?00 oi lhc tihor (xlc.l shrll. ionhwirh comply wirh lh,{ pDlision\
<br />WARNINC Frilur ro s.nrc work.* .onlrniarion cov.mae i\ unlrwtul. .nd shrll suhj(r M.mploycr r. dininrl lEmhas and
<br />.ivil fi0cs un t, oic hundrcd rhouMnd dollr^ ($l(X)). in rdd i,ni n, rhc ro\l of.o ,Nn\{r drnDgcs ar providcd for rh.
<br />S(ti.r 1l)71 .f,h.lalnr(nl. i'{.r.d ind innrtrv'F4q
<br />DECI.AMIION
<br />I hcrcbylmrn unds pcnolryollerjury that I am lieRn uM.r pn'vi\ion ofChaFlcr 9 (comm.cin8 qilh Sction ? Xl)ofDiti\ion:l
<br />ol rhc Busin.s Md Pbfcsions Codc. dd ry li.cn\c is in fuu tnm dxlrlrcr.
<br />7</q/9
<br />qBSIBIJqIIONIENDINIi.&OEN!:X
<br />I hcrcby amnn undcr p..aht ol llciury lhal lhs. k a oisruclion lcnding rlcrcy lor lhc p$formmc ol thc solk for "tich lhn Frmir h
<br />hsucd tsft.1097, civ. c.).
<br />A}]LICANLIIECI,ABAIIO!
<br />I lf,rby afllm u*ler p..nlry or p.rjory on. orrh. rolk,wiig dccla,srknr:
<br />D.nnnit'n Pcnils Asbc{os Norificorion Fcdcnn Rcsularions IIillc40. PM6)
<br />Rc.nncd lrrrcrolNorilicdion
<br />-l
<br />ccnifyllRl thc ltdcrol rc8ulalions rcB$di.8 {sti.{os rc.bvrl c ooritplicnblc Io lhhJ]loFr
<br />I ccnilyrhJl lhM rcndrlri\ |fii.atid dtrd (irc rhnr rh. xhJrd innni(ion i\ coft..r I ilrNt,.o DlyqirhallCii,and Contrry
<br />o,tintr.usntrd Sr c tlwsclarin8 bhxildingco {tudn'n. arxt h.r.hJ_ rurh.rilc rtrcsctrr,ttt\.frhis Ciry ind Connry to cnrcr up.n rhc
<br />r}i,r. icn'i.,ne,l nr,|rcn! lttr 'n,n .l. nurr,*.
<br />O,plr,on, ", n "n,Sir*un/fu2-/24\
<br />,"^**, ^",rn^,t f/
<br />b2/e
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salet y /Low Vollage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilin gs (Hard & Solfit Rouqh
<br />Ceilings (T-Bar Rouqh)
<br />Ivleter Release
<br />Rouqh {-zs4 s y,wld
<br />Service I\/eter ):\
<br />1-17-tK k\4,:,)l
<br />Notes, Remarks , EIC.
<br />Translormers
<br />FINAL
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