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ELECTRICAL-INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER AUILDER DELCARAT'ION
<br />I hcr.by n,tun u8lo p.nJry ol Frru.y $ar I on cxemp! lb,n lhc Conlacro6 Lkcns Llw ,or rhc followinC renv,n (Se.?01 LJ
<br />ausin s ond Profcsio. Cod.): Aoy Cny or Coufll, shth rcqutcs a Fmir ro onsrrud. alrc, ihptovc, dcmolish o! rcpln an,
<br />slruclure. prior ro irs nsu0ncc. lko rcqutcs thc atrlic$l for n'ci Irrdir r. filc d sisftd farcm rh8l hc ot sh. i liccnst Pusunl
<br />!. rhc pftrvisioo\ orrlf, C.nlBclols Licc.pd Lnw (Chnplcr 9, Connncncin8 {irh Scction 70(x) ol Diision,l oflhe Busi..s ind
<br />Pnn ssions C dc) orlhol Ir or shc is excmpl rhcrcfrom and lhc basii ior lhe alkgcd crcnlnraon An, violnlionofsction?031.5 bt !try
<br />aFllic.nr forrpcrnrir subjcch rhc su,licaot ro acivilpcnllrrofmr mrcrhan nve hundrcd dolles {Sr0o).
<br />-1.
<br />as .*n$ of thc ,)$Fny. or my cmlloyEs wilt wa8cs !s tlrt slc c'arprnernrn, will .n th. wor* Md rtr slfu h nor
<br />i'ncdct or.ficrcd (tr ek (S.c 7(N4, Bnrie$ snd Pnrcsions C.dc: l h. conta.lol s Li.cnsc t w docs noi unnly ro u osrcr ot
<br />rhcFmt ny who hnilc\ or inrltrows th.mr d wk' dms such mi( himrclt or hcscli or Ihnlsh his or hct ov..tploy..i,
<br />pmridcd r hlr such inFovcmnls oE mt i.rcndcd or oflcE'd fo. s0lc lt howevcr. thr hnildins or nrqhtft kv,kl*nhD.nc,rr
<br />ofor{,ldion. rh( Owmr BuitLr will h0r tu burdcn of provin8 rh, hc or shc did nor build or irDl,rolc fi. pmFny {or lhc J{rlnr of
<br />-1.
<br />!s owncrofrhc lropcny. omciclusivclrconrrlcting with liccnsd.onttr o^tu.on{n.r rhc pn!.ct (Scc.701,1- Bu\inc.\
<br />andPrltssionCodcrThcc(,r,cr,sLiccnscL0wdocsnorarplyro0nowncroIIrlop€nywnobuildsorimrrovcsrhc.do.
<br />and who co B.Is ld such Plojcts *irh a C.ntnclon s) ltcnsd p!6u ro rhc G).ra.t,r'\ Liccnsc Lrw).
<br />UABTErc]!AMIENIAI1QN
<br />IIECLAEAI]ON
<br />I hcrcby arlirnundft Fmlrroflnjuryonc ollhc nnn,winS d(l rlion!
<br />Ihavcod$rllm trn a Crcn r fi! dc or con{nt r. sc lr- Insun for mrkcm m'n,rcnslrion. o{ rmvidcd t r b, serioo :l?0o ol rhc
<br />I rts Crfhr rhcI]+lro,ruKc n, thc s * I.' uhtrhrhr nfl ,nir r k\u.d
<br />tl,rluvc Jnd *'llmainrar uo*cr' comFnsrhon rn\ursncc. as rcquncd by Secrion l7O0 ot rh. tjhor Codc. lot rh. Frlbnmnc. of
<br />rhc *orklorwhichrhn t'crn r h i$ncd M {l\fl\ otrttF tr{'tr\ trct'.' rfrlp,lr)rlr'l'.'rga)r,tlorrl*-
<br />teL-I
<br />--!rnf r[nr itr rhc lEdnnmncc oI lhc *ok lbrwhichrhis p.flnir ]\ i\\ucd. t shrllnor clnpk)rrnyr.Aon in rny rn,rr
<br />ea\ri,hccorE\uhicrrorhc"lrkcr\$mPti$rnnla*sofCrlinmir.nn.!ncrhdrillshouldbccotruijccrn'rhc
<br />workcr\.ompcn\ariinpn,visi{,n\ofSdcrn,nlT($orrhcLihnGrlc.lrhrll.li,nh*irh.onrplywilhrln,{povnn,n\
<br />\IARNTNC: Failurc ro surc workcn cotrpcn\{ion covcrasc is rtrlawlll. and rhtrlr.ubjcd ar cnl|lorrr ro aiminll pcmxr\ nnd
<br />rivil itrc\ up k, oN hundr.J rhousrnd dollrtrs (Sllx).((x)). tr dirn t) rhc.ost ofconrlicns iotr, d0m8cs !s prolidcd tn rhe
<br />l:'htr(i)dc. Dr.r.n r (lnrtn cy \ 1..\
<br />DECIATA.III}!
<br />I hcnby dmfln u ndcr p.Mhy of pciury rnar I am liencd undcr rovi\ion of Chatrd9lcomri.S eirh sdtion 7000) ofDivnion l
<br />or fie au\iftsr anil Potesionr Cod., {i my lic.ne is in tull forcc ond CITNL
<br />,7tG1k
<br />7 L ,".&oEt^
<br />t0NsI3!cIl(NL!;]ulN!11jIIL!
<br />I hcmby ,lrrf, undcr Fndty of pciury rhll rhE is 0 snslruclbn tdinS agercy ror lhe ll.rfo@r. oa rh. worl for vhjch lhn Irmit t
<br />issucd (Sec 1097. Civ C.)
<br />AIIIICANIIIICI.dIAIION
<br />I h6.6y,fm und.r p.nalt, ol pcrjury oN oflhc followin8 dcclualionsl
<br />Dcn!'lirion Perdir\ A\$c{.\ Noritl.arn,n F.d.rrl Rcgularions (T lc 40. PM6)
<br />Rcquncd ktr.rof Norifi.arion
<br />larions rcgtrdii! aihcstx rnDlrl s. nor{plic$lc ro this pmjccr
<br />pli.dri.n md narc rhd rhc 0hovc inlorm iotr n comcr. I rgre roompl, wirh allCiry rnd cou.ry
<br />ion. d h.rc6y.xlhrrize rcr.scn[rnts olrhir
<br />uhrvc rmnrioocd l)nrpcny
<br />,\ppli.nnl or /\Aenl SianH 'DrLELa)i)7;/;'-"'"
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondinq / Groundino / UFER
<br />Transformers
<br />Torqueing
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilinqs (Hard & Soflit Rouqh
<br />Ceilings (T-Bar Rough)
<br />Ivleter Release
<br />Rough
<br />Service ltrleter
<br />FINAL 9l),ohe i ['-(l4rr€,d,),bX )
<br />Notes Remarks, Etc
<br />APPROVALS
<br />Sub-Panels
<br />I Jmcrcmnr undcr S(rion . B. & P.C. fo' rhn Ea\o.
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