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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hs€by afiinn und6 pftalr, of p.rjury lhal I on c&dpt lmm rh. ContactoB l,ic..* ti* aor rne folloq'ios r.e. (sd 70ll t <br />Rusin6s dd Profdsion Cod€): Any Cily or Coonty qhich rcqut6 . Idnit ro .oBrrud. al6, inprov. dmolilh or E an 8nv <br />srtu.ru.. prior to irs issuan.e, 6bo requts lh. apPlicant for such Fmil ro 6le a siSned slalool l1Bl h. or shc b licd.d p6u l <br />to rh€ proris$ns olthc ( ontoclor's l,ic.n$d lr* (Cn.pb 9. aom'nmcins Nilh S(tion 7000 oi Dilision I ofth. BusinN md <br />Parldtuns Cod.) or lhsr lE or sh€ is .rc6fl ths.ftom and th€ b6is lor thc allcged .lmPlion. Any riolalion of sdrion ?011.5 bv anv <br />applicanr lor ap€mn subjds rh. tpplicantroacililpcnaltyordormor.th.nfiv.fiundEddoll&s($500) <br />I. s orvncr of rhc D.op.ny, or m, anplolB siln sas6 6 rh€n $k .6mpdelion, wiU do rh. *od( dd th. slnElr b ml <br />inrqt(jcd or o,rcr.d for sL (5(.70.14. Busio* &d Aoa6sioE Cod.: Thc Contacrofs Li.as l,s do6 .ol arllv b e orrt ol <br />lh. popcny who tailds or inpm!6 thqsc dd who do6 such $o* hinsclf or hNlf or thmush his o' hd own.nplovc6. <br />prorided rhai such ims.vc@ls d. mt n dddl o, orsld fo. elc. Il, ho*&'6. thc hildins or r1prclaml is sld rvihin on. ,{ <br />of.onpkrFn. rhr O*tra auid6 $ill ha\ c lhc hdo ofrrorin! that ht or she did ml tlild ot inlrove lh. pmpdv lor UE Ftrpo* ot <br />l. s 6wn6 oarh. Drordy. m €xclusivcly coflta.lins wilh licfls.tl Q relo6 to coasrud lhe IFj(l (sd ?04'l B6ins <br />and PFf6sir Codc: Thc Conlmcrois Liccns. tis dos nor apply ro an ownd olprop.ny who builds or inprove rtr@n <br />and $ho .onlmds for suct pojds vih a Co.l,rclo(s) licmrcd pu6udr ro rh. conu.dois Lic@ L!s) <br />I ancrempt undd Sarion A &PC lirrhi rmn <br />WORXERS' CO]IIPENSATION <br />DTCIIAAIIO! <br />I hudy ailrm under torlryofpsjuryo..oarhc follo{ing dEl(.tions <br />I havc and will minroin a Cdificarc of Co6.nr ro s.lf-lNu,. fo! $ork6 conpcslion. 6 FoYid€! lor bt sarion 1700 oflhc <br />LoLBr Code tur th. Pnaortu.. o f thc qorl fo! lvhich thc pdir i3 isludl <br />l/l ha'. aid will mainlain qorktB compc.sario. insuranc.. s r€qutcd by Sd io. lTol] of rhe Libor Cod.. lbr lh. pslort@.c of <br />rhc sork aor rhich lhis p.mn is issued. My wo!k6 conpos.lion iosurdcc trid 4d policy oumb{ e.: <br />.^-,..At<,<d,klgE l c'l<ut I <br />por,rr r.,umu i{ I 4-r CZ1} } paLlg \e qt l@ <br />I cdifyrhal in rh. pdformancc oflhe so loi shichrhisPsmn is issued.lshdll nor mplovanvp$n in a.r,na.ns <br />s s ro he.omc subj6l lo lhc {ort6' conp€neriof, lar s olcalilooia, dd agra lhat if I sbuld b.(o'n subjd lo lhc <br />s.iGl comp€Mtion p,orisioc olsdn,n I700 of th. L,bor Coda I shall. fonhNnn conDly wilh rho* pmvisioN <br />WARNINC: r_dilur. ro sMe $0*6' comllns.r n Nvdtsc is onlsslul. tnd shall subjdl M E.plolt ro qmiral psulliB flnd <br />civil lin6 trp r. onc hund.ed thousud ddll4 (ll0o.0o0). in trddnion lo rhc con of comP€Ntion. ddas6 s p.ovid.{ nr rhe <br />Sdion.1076 ofrh. titu aode. inlq6l dd <br />2 <br />LICENSED CONTIIAC-IOR <br />PTI:IA8AIIO! <br />I hd.!y .mnn und6 p6ahy oa Fjury rtd Ln li.qs.d undd pbrilion oachaplE 9 (&nmdcinS wnh Sdion ,000) of Division ll <br />oa rh. Busin6 Md Prcf*ioB Cod.. &d tuy licffi i. in tull fod and.rdl <br />Clo q5lq <br />",," / ,tz ,/zo <- <br />OA lzct tv1<- <br />I hseb, amrm under Fnahy oapdjury rhd lh6€ n ! conslflclion k dins asdcy tor the ariomance olllE \ro'1 tu $hich rlis lmii is <br />i$!cd (Sr.1097. Civ. C.) <br />Lmds s Nan.: <br />I cnds s ddr6s: <br />AIIf,ICANLDEC!,A8AIIA! <br />I no.t, afDn und6 p.flalty of pojury on. of th. aollo$in8 dclrations: <br />D.molition Pmirs tubGlos Nolificalion Fcd6al R.Culdioft (Tnl. 40. Psl6) <br />R.qun.d Lrrb ol Nolificaion <br />I cdriry $at lh. Lddal rcsulario.u Esardina sb6to! @oval d. nor qlplicsblc to lhi! t oj.ct <br />VI c6,i rhrr I ha,. rqd lhis apghc En od srar. rhd rh. .bor. iifom.rion s .onel I egr* lo cooply wilh aI Cny and Coulv <br />ordinan.B ed sldc l,$s <br />abore 'n6xoncd <br />propdty <br />lo building codndion. md hseby aulhonzt rqrs.nlatir6 oflhis Cily ud Cotrntyto al6 up(ln ihc <br />/z/zo <br />Site-Work <br />Underground <br />Pole Bases <br />Lioht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under SIab / Floor <br />Bonding / Grounding / UFER -\1"w )J(_.tho <br />Transformers <br />Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rouoh <br />Ceilings (T-Bar Rough) <br />Meter Release <br />Rough <br />Service [\4eter \,vlI,l <br />FINAL l -22-71 \'r!'z{CI <br />Notes Remarks Etc <br />L-L -'l <br />",,", I /z /z-ct <br />6IT;'DL <br />-\t-7a