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DATE ID/SIG.COMMENTS OIINIiR AUILDER DELCARATION
<br />I hcrchy oifim undcr lcntrlry of !.rjuy lhll I aD excmnl lmrn lhc Conrracron l.tcise 1,0{ r'or rhe rolldwine rc!{ (se 70:11.5
<br />Blsinc$ lnl Pmfc\rion Codc) Any Ciry or Counry $hth rcquires s Fnnir ro .on{tu.r. ahct. rnPruvc. (hnrlnh or rD{t any
<br />dru.'urc. pri(trro ns hsumcc, dho nqutcs thc,ppli.dnr lnrsu.h lEnnil ro li,c a si8trcd natrmnl thut hco! shc i\ liccnsli l .surir
<br />h rhc px,vht r olrhc Conrractr's ljc.ed ljw (Chaprcr 9, Co'nmc .ii! wirh S.crion 7fiD ot Divnion I ofrnc Busincs and
<br />Prclcssions Codc)orrhd h.orsh. hcxcm rhcrclioNand rhchrsi! fnrhc illqcd cxcmfliotr. Any violali,nofSecrionT0.ll5 hrany
<br />lprlicitrr for o pcrnir subjNls'nc lpplicanr ro acivilFoalryofnor m,c rh3. fivc htrndrcd dollai\ (1500)
<br />_1. r\ owncr ol rhc ptr,Fdy. or my cmplotccs enh wagcr nr r hcn ek Ntr{xnsarion. *ill do E work ond ltE slulmi\ n,l
<br />inrcftl.rl or offcrcd r.r ek lsd.ro14, Busincss ond Pmr.ssi,n* codc: Thc Conr.dors Li.cnrc L.E docr nol arply ro an6*ncr or
<br />lhu nmrcny who buids or inrlrmvcs lhc@n- ard *lm des sEh qo hnnscllorhcGclforrhmushhnorh.r.wncmtloyccs,
<br />l)rolidcd rhsr :u(h i'ntln,hmnt rru mr inrox|t or .ffcR{ f(r *,L. la h{8 , rhc ttrihin8 or nrlr.tlrEnt is bll wirhin orc ra
<br />of.odpLrion. rhu Ow.cr auiucr qillhrvc lnc bxrdcn ol pmving rhd lr or (hc did tror builil or inlPoE rhc F)pcny ri'r rhc ]rurIh\c of
<br />l.,sowNr oirhc pop.n!- a'n.rclu\nrlycotrkxcrin8 wirh lircn\cd r.trtarh\ ro.rtr$ntd Ihc t'nrlcct iSN. ?(}tl. Buems
<br />rM ri.fNsinC'odcrTh.(lonr&roisLiccnscl-rwdocsn.rrptlrroino$nsoipro!.ny$h{)huil&orin,tn,v.srhfco,
<br />ind who co rucls lor such lr!,F.^ *irt ! Conrnck,(s r liccn\cd l]Ur\wn{ b rhc (i,nrrkr'( Li.o\c L.q)
<br />I iDcxc.rDr u.Jcr SL{'ion
<br />Daler Orre.:
<br />w()tlKt R-4, c(ltvt,l'NsAl r(lN
<br />DICI,IBAIIQX
<br />I hcrchy"llirDu cr ncuhy.llfrju'y.ic of rhd fi)lk,wine Jccl ri(rs:
<br />-l
<br />hrvc lndBillmoinhin 0CcrlifiurcofConscnrr. Sclflnsure lor {orkc^ co !,.ns t,n,,\ pi.vidcd itr 6y Scction l7o{r or lhc
<br />L.trtr Codc. ror rhc pcrlo.nEtrcc ot thc *o* ,o. which thc pcrnrir n h{cd.
<br />_l hrirn NillnrirllinsorkcFco'nncn\r(ioiinslBncc.rsrc+irdhysc.ri(,n]7morrhcLahuralxlc.iorrhcp.'ri,ntucc.l
<br />rtu rork,nr which rhhlcrfrir ir iskd Mywork.A contrnsrrion nNurlno.rftlctmd p.licy numhcr sc
<br />f-r^
<br />Vlolfi(t
<br />I (dilirhrr i'! rhc Nnnnun.cofrhc q.rk frr shichrhis |fnnii n n{'cd. l $rll nol cu otrnvr.Aon ir riy.rnocr
<br />si N b hcsrm nrticcr t) th. *olk.n dxnpc.\dnn, hr\ olCtrlihnii. tr'xl i8r. hd 1rl shotrkl hccom {$Fcr ro rhr
<br />workcn conrp.n\rrionIohiof\olSccridr.l?0Oolrhc l: rnC( c. ! shrll. hnhqirh.omfly silhrhsc nn)vi\n,n\
<br />WARNIN(;: Frihr ro r.urc workcr'conf.ns ion c.rcngc i\ ntrh tl. lnd shrll \rbF.r d cnpk,y.r ru.rirnioill]cMllics ond
<br />civil fincs up k) onc hundrcd rhousod dollors (SlU).mO). in iri.f b rh. rod of confrn\nrior, dr ug.s r\ pr,lidcd tur rh.
<br />aIq/8"
<br />inrcrcn ro.lxt(nmy \ ltcsX
<br />I h.nhy rfllrmxnder pcnalry or p.rjury thd I arn li.cn*d lndcr EovGion olChrplq 9(co'nmncin-s *irh Setirtr 7uD) oIDivkio.:l
<br />oI th. Burirc.s otrd Pmfcsions Codc- lnd my liccnE is in full lhc and cr..r
<br />la9liLgifi# .,".-"-dJ
<br />.,,r"', 1t.i At r(f,(8a /tr
<br />J
<br />CANflBIJCIIAN"LENDINC.AGINCT
<br />Ihcrch,stlirdunderFnaliyorpcrjuryrh rhcrd ii0..ndtucrk,n kMi6EaBcr.ylbrlhcp€,fo,rBmc orrhc woik I*Phich rhis Fiinit is
<br />n{rcd rsuc :10'J7. Cir C ).
<br />l-lccn'[ thd lhc lcdsil rsuhron\ rsJlrn8 !.h..r^. rflm\Jl$ n,n rnpl'\rblc h rh.s fniRt
<br />I
<br />$l lfd'ryrh lhtrkrddrhs0r,Fkrnn id {.'A\A,r rhc 0h.tc,nrc,turnn r."ncd lasmror',mnl,
<br />rJ'irn..! J srJr.Irs.rlJlrrr! hurldjtrE(otr.u{"rFn. nltrn'byaurl-oirlcrcr'n.cnrJrih\rrrF.ci')
<br />ah c nf,nrinncd Dmrnr to,n.n.r."n&,/r,a. .I
<br />nrr,,.",,..n*"",r*,","-X lf '{/l- \ D.,e:r
<br />""-u,**.",,n*,,)( NYAE N>t .'.1
<br />drl cou itoo,rquF;rrhc
<br />1p#
<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 />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 (Rouqh)
<br />Ceilings (Hard & Sollit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />Rouqh 3-l D,RI,IC]
<br />Service lrleter V
<br />FINAL t'9"lr *JLTA
<br />Notes, Remarks, Etc.
<br />ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS
<br />AIILICANLIIICI.AB6.IPN
<br />I ho.t y lrIm un.lq rcnalry orl'.rjuryom ofrh. rollowing i,cclarariotrs:
<br />Dcnrlition Pennits-Asbcnos Norific i(,n F.dcrxlRcsulsrions(Tirlc 41). P,n6l
<br />-Rcquncd
<br />kllcr of Norifi calion
<br />lt/leter Release
<br />I
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