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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground 7-21-lg v.v*a)
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Lite Satety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFEB
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilinqs (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rough)
<br />,/a--\
<br />Rough 7-z+.-lI \.vL1*))
<br />Service Ir/eter \<
<br />FINAL 7.-zr-ly )t"wtJ
<br />Notes, Remarks, Etc.\_-/
<br />OWNER BUILDER DEI,CARATION
<br />I hcrchy ufirm undcr pcnalry ol Erjury lhal I !n cxenu ircm lhc Conlraclor' I-t n$ hw l;r rh. rollowing raion (5(.7011.5
<br />Burincs lrn Aoa€sion Codc): Any Cn, or Couhry which rcqut$ a pcmrir b c,nsr d. alrd. i.rr.ovc, dcnnlnh o, rct{t dn,
<br />$tu.rfiu. rritrb ns is\u!tu.. rho mquircs rh.nmli.anr rd sn.hFmI ro filc n siSncd srkrrcn' rh,i hcorsh. n liccnsd punuMt
<br />ro Ihc fmvkions of rhc Conxrcln s t-iccnscd L0* (Chaprer 9, Commencins wirh Sccrion T()Oi) of Divi\ion -l orrh. Bu\in.s rnd
<br />PmfcssionsCodc)orrhor trorsic i\ cicnfl rhcrcfromrnd thc hash l'or rhc alle-ged crcmprion. Any viotlrionorSerknTosl J byany
<br />rppli.lnr lor a pcmrir srhj$t rhc rptli.rnr b rcivilrctuhyDfnor tux. rhM fiv. hrndrcd dollrs (S50O)
<br />-1..\
<br />owrcroflhc pmlrn]. or nr, cmploycc\ wirh wagcs as lhcir $lc conrpcnsrlion. willdo Ihc w.rk dxl thc srruturc is nol
<br />irlcri.d or !flcrd tu slc i S( ?044, Busirc$ ,nd Prordsio s Codc Thc Co.rrdois Liccnr L4q docs nor lplly ro u oNncr oa
<br />rhc pmpcny who builds.r inrroE rlErcn. ui sho dms such sorl him\clfor hcrsclfor rhmuEh hh or h$ o*n cnployccs.
<br />providcd rh.r such nnlrov.mnF N nor intRL\l or oficBl for st l( ln'swr. rn t[ i*liq or i'rgm,ecmnr iq r,ld wirhir orE )qt
<br />of.om.rirn.rhcowNrBuih$willhrEthchunlctroiln)vn,Brharhcorsh.dilmtttrildorimpmvcrhcpmltnyforrt Inqil{or
<br />l. r\ ovnn.rrhc Imrdy. ancxclusivclyconn ring *irh lic.ns.d conr.ctor roconnfld lhc pr.j.rr (Scc ?(!4. B!\urcss
<br />rnd h.fc$hn Codc lhcConrracloasLiccn\c La* docs nolapplllo!nosner.apbr. yqho boildsor impii,vcs rhcrcon.
<br />itrd who.onrmrsrdsuchpn+dswnhaConhcro(s)liccns.nNNitrrrothcConlracrolsLi.enscLa*)
<br />?c,/{
<br />DECIIIIA.IIIIN
<br />I hcrcby lffirm undcr Fnohy of pcrjury orc ot lhc lolloBing dccllBl ions:
<br />-lhrwandwiumi
<br />dnnccnnicrlcofconscnrbSclf.lnsurcforworknscompctrsrion.asrmvidcdr'orbySccrnrnITOOolrhc
<br />t [or Gdc. r.. rhc lcdolr1M. of fic ]brk ror which rh. pdmir i! i*su.d.
<br />_l holc rnd will nrainloia wortc^ compensation insuEncc, us rcquiEd bySdbn l70O.rrhc tjb.r Codc. ior thc p.rformmc ol'
<br />thc Nork for whkh lhn p.mit is n$cd. My sorkc6' .omrcnsarion inslratuc csi( ,rd Flk, ntrnb.r m
<br />-l
<br />ccrlily rhil in Ihc l.rlornrer ofrh. w.rl tn which rhis Fnnir is i\sucd. l \h.llnor cmfloy lny pcmon in.ny rooncr
<br />$ ,rt,ls.nr slbrcd ro rh. *o.rcn ompcnqrion hws of aalirornir, daaEcrhrr ilI sh.uld hccoB subjcd rothc
<br />work.s.ompcnc iontrcrisionso{Scclionl70ootth.trhtrCod.,Irlmll,fonh!irhomply*irhrho*Dn,vnn,N..
<br />WARNINGT rarlurc tu w!,c $orkc6 co.rFnsurion mvcBsc is unhwful. and nhll subli nn ohpk ru u aimin0l,tMltas and
<br />civil finc\ u! lo om hundrcd lfiolsrnd dollar (i100.(t)O), in addirioo
<br />'o
<br />rh..oi or co'npcnsalion. domscs !s plovacd aor rhc
<br />Scc'iun.1076ollhc tr6o! 4oJc. io'urcduJ u "tr.!'\ r.r\
<br />,,,". ) /r fu/u "/ k no,,,-*A /4 .,*4L
<br />Lt( F(\Fn ( (|N',l',R CfoR
<br />DECT.AaAIIaN
<br />I hcal,y dlrm undcr pcnslryofn rjury rh0r I tr.r l,.cn*lundc. pmvhion ofChaplcr 9lcommrcitrB wilh Scdn,n'7000) orDivilion l
<br />of lhc Businc$ md Pmtcssions Code, ard o, li.cnc is in tull fo@ ad .firr.
<br />AIILTANfDECLAAAIPN
<br />I hdrt'yaJfrnrndfi F.n y ofFrjury om ollhc followinS d(lmtions
<br />Dclmlition Pcrnils'Asbcsros Norificarion F.dcrsl R.sullrioos(Tirlc40. Pnn6)
<br />-Rcquncd
<br />L€ttcr olNorifi dion
<br />I ccdiry rhilh. r.dc.al Egul,rio.s rglrdin8 asbcsros r.mvd 0rc m' lrplicahle ro lht p,oi{r
<br />-l
<br />cdrily lhol I Mvc rc$d thk lpllnrrn,n anl ddc rhar rhc uh,vc nrioruridr i\.odccr. I iSre ro.omplywirh aU CU lnd Counry
<br />onlinrncc\ md Starc tiws rcbr ins x, hu ildins con{rucrio!, orn herchy aurlxtri2e Eprs.iorilt\ ,,r rhi\ Ciryud(t,untyh cnlc, rlili rlt
<br />fto\c rnrn,.d /op.nylnr i.sF{(iotr purposcs.
<br />A0dicn t.r Asol Silnnluft z/ze4a€
<br />IMeter Release
<br />g}NIIAICIIONIENIIIIIG-AGEICI
<br />I h.rcby lrfiro.lnd$ Fnalty or Frjury rhd llrcrc n r oNlruct k n hndin8 a8crcy tor rhc r.rfomte ot tli. wrt for *hih thn Fnil ir
<br />issucd (SE. 309?. Civ.C.).
<br />Lcndcr': Nrmc.
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<br />knd.r'( Addrrr
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