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APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground q//d/l t ?-tkto*
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rouqh)
<br />Meter Release
<br />Rough
<br />1Service [\,4eter I
<br />FINAL / / ?41741,,n //L ft{/
<br />Notes, Remark/, EtQ. /
<br />0 (-
<br />2-o Tts
<br />OWNER BU!LDER DEI,CARATION
<br />I ha.b, amm undd p..ahy ol psjury thal I m cr.ofl fmd lh. ContacloE Licos L.s' lor lhc followinS r.ea (Sa 70i I 5
<br />Itusin6s ard Prof6ior Codc) Any Ciry or corn'y whi.h r.qund t p6mn Io coNrod, tlrd, improvq ddnolish or radn ey
<br />srrucru.. Fior to ns sudc.. d.o r.qut6lh. applicul for such p.rd ls nlc a sic..d sl.ldot lhd hl or shc is li.aGl puc{li
<br />ro th. pmvtioB oalh. Conterois L&nrd Lr{ (Chapld 9. Com,ntrins tr'IIh S(rion 7000 oaDiniion I oflh. Busi.e dd
<br />Pmfcsions Cod.) or rhar h. or snc s .lofl lh@&om sd rhc b€sis ior lh. allcs.d croFio. Anyviolalionofscclion 70115 bry any
<br />agplica.t for a p.mit lobjdlsrlrc applic0nl to acivilp.nohyolnol fror.rhe 6!. hu.dt.d dollm (t500) ,
<br />l- ar oMd.lrh. proFnt, or ny cnployB *ilh LvasB s lhcir sL c.6pdsaiion. silldo ltE wort rd tlE nruci@ k mr
<br />inlodcd or oil6.d ior ek (S8.7M4. Burins dd Pro l6ioB Con.: Th. Conlradois l,icm. Ltw do6 not .p?ly lo M oNna of
<br />th.F.tdry trk1liil& or iniFov6lhoun. ud *ho dE ech trrfi hins.lfor h6.lao. thmu3t his o.nd o*ndploy6.
<br />ttrovid.d thar su.h inpr.rmaB eml int.nd.d ororladl forsk tt hosd6, rh. hildin* or inpmvdnq i!sUwnhi....ya
<br />ofconpkio.. lh. Oqr6 Build6 *ill l'a( $. brd6 of pmving lhd hc or shc dn not build oi imFo!. [E Fopcty tur lh. p{.Fe ol
<br />l. 6 oMo ofrhc proFry. M n.lusiv.ly codradins wirfi licasd .onlra.166 ro codtud ih. Fojd (Sr. 7044, BGind
<br />and hrftaeioncod.r Th.Conlracloas t-icds. Liw dod not.rplyro Moend ofpropdywho build! or inprovd lh6mn.
<br />aod sho codrads for 3uch Fojds u'ilh o Contclo(s) licos.d puBMt b th.conkeclois Licmc lrw)
<br />I mcr.hpr unda Sdlion .B &PC lo,rhi! r6on
<br />D.r. Orner
<br />]IOBf,EBI-(OIITEdIAIIOX
<br />DEC]dNAITIIT
<br />I ndcb, am n undd F.ahy or prjury on. oarh. aolloving d(ld io6:
<br />I hs\r {d will mainllin ! Ccnificarc of CoNdr r. s.lf-lNrr. for lorks coq@r.rion, d ,rorid.d lor by S<tion ]700 ol rh.
<br />t b.r cod.. aor lh. p6lom c€oflhctroAfo' i.h lh. pdmn k isuJ.
<br />I harr and s ill nainrain *ortm comp.Nalion insurorcc. s Equt d by s<r io. 1700 olln Libor Codr, for lh. pdaomMc. ol
<br />rh. rvork tr which rhis ldnit i! i$!.d My trorks c!'rpdsdion irsure..mid tnd Polt, numb( 6.:
<br />lcelliyrhar inrh. pdLman.. ol I hc rork for\vhich lh6r.mril
<br />'s
<br />6su.n.l shallml drnloyanyps$. ina6r,r fd
<br />s 6ro b.$N. subrd to thc\0*6 cofrl.Gari.n lass.fcaliLmi.. and.sr thd ifl should b..om. bjd tolh.
<br />$0*6 co,npaslionpmvisionsolserionlToooarfi.litrrCod..lsrrallronh$ h .omPly with rhoF provisioN
<br />wARi\lNC l;ailurc to su'. trlrlc6 contmsrlion.o\ch!. k unhsful. and sh.ll luhBr an mpk'yd to orinrl FEki6 t.J
<br />.nil nn6 up ro otrc htrndrcd lhousd dollas (00.m01, in addnion lo lhc con ol c.,npdario., dmas6 s lolid.d for rh.
<br />sdrim (176.lrlf l.hnr aod.-r* Jl./^ Grlz\
<br />w'u->r 6b (bur Ay BorcLTtJGCo.* lzslrl
<br />!tllj-!!-!jl-!ll!!!!{ ra!!
<br />I h.r.br afl-'im undd pdally o I pcrjury
<br />DTCJ.AtsAIIA!
<br />utrdq rm\ isnnr ol( haprs t) (commocins rih sdion 7000).fDntion !
<br />ol rhc Eusincsad Proa6sions (.d.,.nd D!. licor
<br />Y)to"5Ll6S
<br />*lz ,E , Nf ,[Je{i}tr4.Y 8,1 | L-b/PLa a2
<br />I hs.by smrm und6 p.nahy ofpdj!ry I
<br />issocd (S.. 1097, Civ. C )
<br />l<nd6'sN.m.:
<br />n k dinr arnc! for lh. psfon.anc. orlh. *.tk aor N cn lhis Pdflil i3
<br />AITIICANLOEIIdAAII(I!
<br />l@afm undd p.nahy of pdjtrry on. of rh. follosin8 d(lualionu
<br />Dmolirion P.mils-Asb6ros Norific.rio. F.ddal R.8obt ions (Tnk 40. Ful6)
<br />R.quircd t ttdolNolificalion
<br />,.6rrD rhd rh.,Nn,l '.!ul,'oB r.strdrn8 6b6r.\ rcr \als. rd arpl.(ahl.ro,hr p.id
<br />/,^^\^ r1,,-",n"annl'(,,i,n ud s.rcrhar !h. dtnv. ,nfonnarn'n is cord la3!atocomprtRnhrrr( yand(ounry
<br />([dma(6 an,hd. LA\s Eldins r. h{,ldms coNruc!'nr dd hs.by auihoiz. r.Ir64taliv6 ollhi Ciry sd Corf,tylo et( ulon th.
<br />ah". no,-n.y'lqp.n) ro, ,spa,Fn p{rx,s M /Lilz\-
<br />:,,;:;;. t;;;'.r.i, vt"oi)-77 1u,'0,u6 "o ^,", +/14/t7
<br />*.*,* -..'tp,,,/ tutt't' 6QoaLu-A( 0t+ttu6 ce
<br />-T--
<br />ELECTRICAL-INSPECTOR RECORD
<br />w\ Ar-i Me>5*,*
<br />tr/lY/lfr' rLrL /N?,
<br />I
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