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ELECTRICAL-INSPECTOR RECORD
<br />ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrc6, lmfln uMcr penalty ()l lcriury lhal I dn crcmB for llr Conl,0doN Lkcn$ l,w aor lhr followiry rcasn (ss.'?011.5
<br />Bu\incs ani Pofc$ioo Cod.): Any Cny or Counry whth rcquircs u pcrmir ro coi{rucr. !hcr, iFprow, d.mo}Gh or rcnrn ony
<br />slruclur.,,,in to irs hsu&c..8tso rcquircs rhc rp/i.dnr nrsuch Fnn[ t' firca si8ncd sorcmnl th.l hcor shc h liccnscd pusunnt
<br />o rhc pmvli.ns of rhc Conrrrcrors Liceord Liq (Chaflcr 9- Co.mErcin-q wirt Sccrn,n ?(x)O ot Divhion I ofrhc Busin.s rnd
<br />Ptufcssidns Cod.) 6, rhdr lf, or shc B erc$pr thcefronrnd rhe harn fu rhr,llcEcdcxcmfltJn Any vn,hrkrnorsdrio.703l.5 br rny
<br />rlplicant ror ! p.rmit suhjNt rho appli..nrto,.ivilr.d,hyot( norc rhM fiv. hundr.d dollrs ($5oo)
<br />I. rs osi.r of rhc pn,IEdt, .r my .rfloy.es wirh wrg.s !s rhcn $b ..nl.nsir ion. will do rlr woA fil ih. srulm h nol
<br />irrcndcd or ofic,cd rbr $lc (Sa.7044- gusinc$ and Pmlcsiotr! Codc The Conrrlols l,ten{ ljw dcr nol amly ro dn .wner or
<br />rh. ttuFny who boildlor irpioq rhcN[ od *ho des suh ud* himsclfor hcr$lfo. thmu8h hh or hcr owncmplott.r,
<br />pmvnlcd rhar \uch in,Frvc.rnB src ior inrcndcd or oilcr.d f(n {b ll howcwr, rh. huikl ing .r inpmrcnrN k $ld wiririn om }w
<br />al s,trtLlion. lh. Owns Bui!.r will harc tlE hinhn or E.ving rhni h. or shc dil nol buiH or impmrc lhe Impcny lor rhc p!ry,{ of
<br />-1.
<br />rs.{ncrol rhc tDpeny. ancrclusivclyconrracrins wirh lirenscd conrrcror ro connrud rhc pn,Jccr lscc ?o14. Bu$N$
<br />a Pilf$sin C.dc lhcConlrdcttr s Li.cnsc Lrs docs nur rflrlyro nn owrcr of prorny who buildsor tnpn,vcs rhcr.oi.
<br />rnJ who.onrra.hntrsuchpnF(wirl,trCotrrDcb(nlircn\cdIu6urnrbrhcContd.ttr\l-k.n\cLrq)
<br />I rfrcrcnr0 ttu|., Sorri,
<br />u*" aa|43
<br />DICLABAIIA!
<br />I hf.bt afl lrnr undcr lcnrlrt of l{rjory or of Ihc f('lk)*nrt drrlrrrion\:
<br />I hi\r rfti $illtuinrdnaCcdiil.atcofC.tr*nru Sdlf lnsrrc t(r {orkds'.rDp.nsarion. $ fovidcd l'orbyScdnu l70Ool rhe
<br />Uho, Codc. for rhc lsforromc olrhc *.rk fitr *hich lhc pcrnril is hslcd
<br />I hrvc riJ sillnhi'nrnr w.rko a .otrrt{r\dn insurrnru, as toqrn.d htSccrrr lTOrolrhc Laior (idc.lbrrhc pcnnn,umrol
<br />rhc *orklnr qh,.hrhn p.i,nn rs is$cd Nlylorkcn .oDrrcn\di(n i'rsurnDcc .aricr ind |Dlicy numhcr oc
<br />-lccnifyrh,l
<br />inlhc pcrio!ronccoalhc work nnuhich thir i.nnil i\ nsucd.I shall n rdmploy rnyllcrsn in dnyn'anncr
<br />s !( t, bcconr sobjd t,
<br />'hc
<br />worksi c.nrr. \arbn hws orcflUlnrnir. tud r!rc. rhar if I rhould h..om shjcct l{' the
<br />worlc( comFns ion pmvisions of SLrrtun 37mof rhc Lah,CDdc.l shsll.lonhwirhconrply sir[rhosc prcv&bns
<br />WARN'NC Frilurc to $curc mrkcF co'npcn\arion colcrnsc is unuwlnl md \hrll *rhjc.r en cfifk,ycr ro dimirilpcnallics ttrd
<br />civil rnr\ !p k, onc huJrcJ rhousiDd Jol[^ (]ll{x).rxxD. in l(liri,rhc c.i ofcotrlP.n\rrn{ dr u'!c( rs t)
<br />Sc.rion Jl)?6olrhc Lrhtr Codc. i c.cd r.d trrtmcy s lccs
<br />u^",7'31 .R
<br />AECIdSADAN
<br />I hcEby amrmundc. rcnahy ot pcrjury rh.r I ah lienst undcr r,{,vhion ofChnplcr 9 (d,n'n*nci.g wir
<br />of th. Busirc$alld PmfcssionsCodc. and nryliccns is in tull loN 0dcffNr
<br />toNiirxutt[]xLElDlNc-ac[lcr
<br />I hceht allirm und.r Fnalrrofpojury rhol th.rc is d..n{nr.rioi kndirS rScncy lu lhc pcni.nroN. olrhc sqk tbr shich rhi\ Fnnn n
<br />hsudd(Scc:l097.Civ C)
<br />L.rdcl! Nontr
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<br />ATILICANI.IECLIM.IIO!
<br />I h.n*ry amm xndo F.al(, or Frjury o.c .r rhc follo{ing dccldar it r:
<br />D.nnirion Pcrmih Aibesros NorifEarion tueral Rcsul.rions (Tirlc40, Pan6)
<br />_Requted l,rler of flrifi carir
<br />l.rdilirhrr rhc lcd.Blrcgulnrir) \ r!:trdi'rS r\hcno\ rfln.Mlr.c nort'mlnrbk r) rIn 0R)1..r
<br />-l
<br />ccnnirhar I tuvc rctul lhh 0lrlication lnd (olc I rlDvc irlnm idr is.on.cl I a8rccrocomrl ) NirhrLlt-ir\ rnd (i{n \
<br />, xnil(,i y(, fl .' ri{rrh.odiMnccr s Srorctiwsrchin8 rol,uildir8
<br />!h.vc nEnrioncd por.dy 16r insp..r
<br />Apnliunl or Acenl SEn.lrr
<br />S HDRAY
<br />?-3t'18
<br />Site-Work
<br />Unde rground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Air Condilioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Sollit Rouoh
<br />Ceilings (T-Bar Bouqh)
<br />1f .t- t(J),ti'W w
<br />I
<br />Rough
<br />Service [t/leter ,
<br />FINAL Q-1 -19 -l) "(,{"'tl )vNotesRemarksEtc.
<br />APPHOVALS DATE
<br />[/]eter Release
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