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ELECTRICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BT]II-I)ER DEI,CARATmN I hcrchy allirnr undcr l^-trxlty of pcrjury lhal I rm ercnril lr)nl thc Conlmck)r' Liccnsc I.iw lbr thc lblltwirg rcxson'lScc.7t)-l1.5 Bu\i,lcss ud Prol'csri()n Crxlc): Any City or C(trrnly which rcqililcs a lrnnit lo cr)nslnr(l. allcr. inrprovc. dcnrrlish or ll])air anv slnrclurc.fri()rk)ils issuancc.al\orcquircslhcrfplicanlkilsuchlL-nnilk)lilca\igncd\trlcn*nl lhxtlrcorsht'islicenscrJ purruard applieilDtli)ral--rmitsuhjcetsthe applicnnlk)rcivilp(-nnllyolnollx)rclhinlivchundrcdtkrllarr($500). _1. as owncr ol'the prolrcfl y. or my cmpk)yccs with wagcs rs thcir sr)lc crmllrcnsali()n. will do llrc work an(l thc slnrcluc is nol intcn(lcd orolltrcdli)rsnlc(Scc.7044.8!sircssandProli's\urnsCodc:'Ihc(iulraclor'sl,iuctrscLawd()csndapplytrdnowncro[ thcpt\)Fny whohuildsorimp(rvcsthcB)n.mlwhod(rssuchworthinr\cll'orhersellorthroughhisorhcrowncnrployccs. providc(lthatsuch irrprovcrmntsmnotintcndcdorolltrcdli)rsalc.ll.lx)wcvcr,lhchuiLlingorimprrverrrcilliss)hlwithin(nrcycar ol complcli)n, thc Owner Buildcr wil fuvc tlrc hurden ol p.oving llrat hc rrr shc rlid n(il build or improve thc pff)ffry for lhc purF)sol' $alc). _1. r\ r)wncr ol'thc plopcny. anr c\alusivclv c(,ntraclllg wilh liccn\cd coDtrrctoB kr (1rn\lnrrl tlr pfi)j('cl (Scc. 7044. Uusirrr'sr and lhrlirs\ktrlCodc:TheContra(k)r'sl,iccrlscLnwrlocsD()tnpplyloro()wn.'rol'pri)1^*rtywhobuildsorirnfr)vcslhcrc()n. !nd whr) eonlmcls li)r such projccts wilh r Cor)trackrr(s) liccnscd fursiliDl k) thc (inilrack)r'\ [-iccnse l-aw). -IanlcxcmptundcrSccl()n-'B,&P,C,li)rlhislcas(,l,l)aler- EQ8&EBL!9UfjNSAT!!IN DECLARATION l hcrchy allirnl urdcr t^-ully ot pcrjury onc ol'lhc lirlk)win8 dcelaralionsl lilx)r (lodc, lbr lh(. pcrli)rnrancc ol thc wl,rk lor whieh lhc Nrnril is i\sucd. thc w(,rk li)r whle h lhis l^-rmil is issued. My workers c()nrl)cnsalirnr insuranrc canicr rurl la)licy nuNhcr iuc: Poliey Nurrbcr: _l ecnil-v lhal in lhc pcrli)finnncc ol lhc work lor which lhi( I-_rnrit i\ iqrusl. I shall n(il .tr)Ikrv aDv Frsr)t in rny nrnuncr sr) as lo hceonr suhjcct k) thc w()rkcrs' ci)nlpcn\{li()tr liws ()l ('rlitbrnir, and agrcc lhal il'l sho[ld lEConE suhj(,ct k) thc workcrs'crnnpcnsalir)npR)vi\i(nrs()lS!'ctin.l7(X)i)lthclrlx)r(ixlc.lshxll.l'(rlhwrlhcoil)plywiththoscptovi{i(ms.. IVARNINO: I'ailurc to t'curt- work('rs (onrFDsrt()n covtlrrt- is u rn(l \hrll \lrli('(t xrr .nll)l()vcr lo crinri,rrl lrrnltic\ aBl civil llncs np tr onc hundr.d thous{nd dollars (Sl{X).(xX)). !r tr) lhc co\t {)l !iltrIl}ctrsntion. danrrpr.s as pr()!'trlc(l li)r thc Sccti()n Lahl (ixlc. trtcrcst rnd itk)nrcy \ li-cs. I hcrchy allirn undcr F-nillly ol |trjury lhat I DI]CI,ARA'I'ION uD(lcr provisiril r)l Chaptcr 9 (ronlnf,n(in8 with Scct(rr 7fi)0) ol l)i!isirr .l ()l lhc Ilusillcs\ nnrl Pr1)l!'\sx)n\ (ixlc. u(l i\ in lull lor(c rnil clle(l l-icr'nst'Chss:No I I hcrchy alllrrrl undcr l^-nrlty of rcrjury lhrt llNrc is n conslrcl([ hndrng apency li]r lhc pcrlirrnancc of thc work lor which this pcrnril is issued (Scc. -1097, Civ. C.). kndcr's Name: lrrxlcr's Addrcss: APPI,ICANT DECLARATION I hcrchy allimr undcr penrlty ol pcrjury onc of lhc li)lk)wing dcchril( i0ns: Dcnx)liti()n Pcrmits-Ashcstr)s Noliiicalion ltcdcrdl Rcgnhlions ( l itlc 41,. Pili6) _Rcquircd lrllcr ot N({iticxlion _l ccrl rly thrt thc l(dcrrl regulxlir)ns ('giriiir! r\tf,'\los r cr!!vrl i[(' rn{ xpltlirrhlc k) lhr\ proir( I ahrrc nrcntrrncrl pl,rpcrly 1,tr trr(l)c(tirln Applicarl or Agrnl Itcrtrrilee Dilnrc I u^r",1 t7? Site-Work Underqround Pole Bases Light Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Building Under Slab / Floor Bondino / Groundinq / UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rough) Ceilinqs (Hard & Soffit Rouqh Ceilinos (T-Bar Rouqh) Meter Release Rouqh Service [Meter I FINAL Lold tC 1 1,1 A).LA.A'w) Remarks Etc