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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.OWNER BUILDER DELCARATION <br />I h.rcby afftrm und.r p.nllly of Frjuly lhtrl I dn cx.qrt liom ltc Co.rructou Ltcnc Law nn lhc fdlloein3 reo$n (S.c7031.5 <br />Busnrcs and P.ofc$ion Codc): Any City or Counly lhich caltcs a p(dil io con{fl.r, ,hd. improvc. domlish or EFr lny <br />dtucrurc. IJr r. irs isrrfte, rl$ rcqun q thc,fi,ltanr ror cuch IBm[ ro Iih c siBmd st{tcnrnt lh8l lEor sh€ is liccnEd punumt <br />ro lhc Fovhions ot rtE Conrracrois Licensd Liw (Chrfl.r 9, Commcncin8 witb ssrion 70u) of oivision 3 of rrE Busim$ and <br />Porcsions codc) or rhar tEor shc is.xcmpr rhcrcliom ond thc&sh fot lh. ullqcdcxcmflion. A.y violario.ofs&rion?0:ll5 byany <br />lpplicunr f{tr upcrmir suhJecrs rhc rnplica.rbacivilpcnaxyor.ormrcrhanllv.hundr.ddollris(5500). <br />l. as ouncr of rhc lrrotcny. .r nry cnrtloltcs *irh s!3c\ as rh.ir {,lc .odPtnsdnrn. sill do th. wott drd rhc suru. ( mt <br />i' r [a] or oflcmd nr eh (Sm 7(X.4. arsitus dd l\ofc$nrN C.dd: Thc Conra.kr's Li(cnrc tr* does nol qrDly to an owftr oi <br />rhc tmFny wtx' hnink or i'nprcvcs rltEn,. rxl who dm\ such w,rl him{llor hcr{lfur rhn,u8h hi! or h.r o*.cn{k)yccs, <br />provilcdrhrr ru.h impmwrm sGrDt imd'lalolrltrcd lor slk l( howcEL rlE triuing or nrymEftm i\skl wirhino't rtr <br />ol co'qrLrin. rh. Owmr Bxild.r w l hlk rtr hordcn of JhvinB rhnr tE o. shc dil ml toild or inpmlc th. pmFny for llE purIrs of <br />l. $ owncr oi rhc pmr.ny. am cxclurircly conrructins sirh licen*t conrru.!.r t, on{fl.r rhc prcFr l s.. 704.1, ausnrc$ <br />a l lifssbn Cod.: ThcConrr.ror's Li.rnsc Lawdocs frn rrl,ly ro an owncr of !rcJlcny who huildsor imtrovcs rhcron. <br />lnd who conrmrs lor such rmj.rls wi'h a Conr.acro(s) liccnscd po^unm t, rh. Conh.roas Li...sc b*). <br />DDCIAXAIIA! <br />I hcrcby rfilrnundcr NMlry.l p.rjury onc olrhc knbwlll8 dccll.xion\ <br />_l harc d w,llrMinrain. ccdifralc ofConsctrl ro Sclf.lnsurc tor workcG onrycrstjon. as Imvidcd forhySecrn,n:lT0Ooflhc <br />tjk r C{)dc, tirr rhc ,.rfornun c .f rhc *ofk f.r whi.h th. p..mn is ksucn <br />_l havc rnd uillnrinhin workd^ .onp.nsarion inrutun.c,.s Ntuncd bySccrionlTO0nil& Libor Codc.lor lh. rc orronccof <br />rhc work a{tr whirh rhr Frnrir i\ nskd My*ork.h co.qEnsarion rnsumnc.fftr n p.[cy numh.r dc <br />I ccnilylhrrin rhc pcrrb unccoIlhc'orkturhichrhnFnniri\k\ucd,Ishrllnotcn\ployinyI.*oninrnyn'Mmr <br />$ us h hc(nm subjcd t, rhc sorkc^' comp. n\srn,n h*s of C.librnir. and +mc lhil if I should hccom subj.rt lo th. <br />workc^.o'nptn\rrionpmvNi{,n\ofSL{ri,,nl7(x)ofthctjborCodc.lshrll.lonhqirhc.nrllywilhthoEpmvisn'ns.. <br />WARNING roilurc lo scurc work$s' conDcnsdion covcr4c i\ unhrlul. !n shull suhicr rn.nrlo)tr rd diminalrrtulrts rnd <br />civil lincs up b onc hundrcd thousmd dollar (ll(Xl. X)1. in ddirn,n h rh..oi of co'nFnsiliotr. danu3.s !s lrovidcd for rh.6'Sccrio.1076 dfrhc Uborca c, i'tcrc( md r(ormy s fc\. <br />7 <br />DECIJMIION <br />I hcEby af6rn unncr pcnahy oipcrjury thll I !m [en*d utrdcr pmvhion olChllrq 9 (commrcins qirh Sccrbn ?000) ofDieiion:] <br />ul rh. Busincs Md P,Dfc$ions Codc. {i my lkcnsc is in tull f.rcc un cfir..t. <br />CONiiIf,U(IIONIENDIIIIGENCI <br />I hcrby amrm undfi pcnalry df l.rnry rhu rhcE a.onntu.ri.n lcndine aB.ncy fo.lhc p.rform a of rnc wort for whih lht lrrmit is <br />hsucd (Sa.:1097, Civ C ) <br />L(ndc ' NJn( <br />- <br />AIIUCANfDECI.dAAIIAN <br />I hdEt'y ntinn undd p.nrlry orp.rury otu otrtu aollowi.s dNlurtn n\l <br />O.mlition Pcrmih-Ashcnos Norificdirn Fcdcrd RcSulriiotrs (Tnt 40. Pun6) <br />Rcquncd btrcr of Norificaio. <br />I.cnilyrhJrrh.Ld.rrr.gulrrtr,n\r.!idn,!J\h({ovrnn)lrlrrc,Irft)li.xblcbrhi\|m]_.r <br />_l.cnirirhd I hrvc rcrd rhis.t'd{[otruld rcrhd l}E.hor inlhm ionisc.trccr Lsre h oryly wirh rll Cir] and Counry <br />onlinan.cs and Slitc L2ws Elaling lo buildirS conslfl clion. <br />rhrvr mnriomd ptup.dt for insr..rnn <br />,\t,t,lir lor,\,tr lSix.rlu <br />aurhoriz. rcprc\cnrarivc\,'frhi\ Cir, and Codnryh cnrcr uF'n rhc <br />Site-Work <br />Underground <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (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 />Torqueino <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soffit Rouqh <br />Ceilinqs (T-Bar Rouqh) <br />Itleter Release <br />Rouqh <br />Service ltrleter <br />7 -tr- 2t *arf.l2 <br />Notes, Remarks, Etc <br />Rnv 08 07 2015 <br />COMMENTS <br />Pole Bases <br />FINAL <br />._l Jmcrc'nnr Lndfl s*'on-. B a P.C.lorrhs r.rsq, t;" <br />-**@o <br />WbR{EiascoMiENsATroN' <br />Conl*lor: <br />Lrn'lc' .i A'lilrs <br />- <br />I <br />=