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APPROVALS DATE ID/SIG.COMMENTS OWNER BUTLDER DELCAIIATION
<br />I h.rcby affifln undcr pcnshy oI pcrrury lhal I om cxcnrpt fmm lhc ConlracroF Liccnr Lr* for rhc rollowin8 rcn$n (Ss.?011.5
<br />Busincs lnd Prclcssion Code): Any Cil, or Counry which rcqutE fl rimir k $mrud. .h.r, improvc. dcmlnh nr rcnnt rny
<br />idcruc. lrir ro irs isslaftc. ils. rcqxircs rh. {prlhdr f.r sxch Fnnir lo lilc ! si3trcn slalcmnl rhll hc or rh. ir li.cnscd ,)UNMi
<br />to thc prcvisiotrs of rne ConrDciois l,iccn$d Lrw (Chaprer 9- ComhcMing wirh scctiotr ?mo of Divtion :l otrhc Btr.i.c$ a
<br />Pft,r.ssionr Cod.t oi rhdr t*.rsh. iscxcmpr rhcEfromatrdrhc blst lb! rhe lllcged cienflioi Anyvn,hrionofSdliotrT0Sl 5byan,
<br />anDlicanr lor ! pcnnii subjccrs rh. aprlic,nr k, acivil penalryotnoi n r. rhM fiv. hundr.rt dollrs ($5m)
<br />l. N owncr .r rhc prup.rly. .r nry cn[loyccs with waScs ns r hcir $lc clnrpcnslri('n. will do rhc wi,fk and rh. nMur is nol
<br />imc .d or oilcrcd ntr ek (SE.7O&, Businc$ and Prcrcssion\ C-qlc: Tnt (-onr.dor's Li..tr{ tjw dms noi atply ro an osns of
<br />rhc pmpcn, wk' t{ilG or imEoRs rh.Nn. d who dds skh m& hi'nscll or hcsclf or Ihmu8h hh o! hcr own cEployc.\,
<br />lmvidcd rhor such impmvcnrnl{ m mr inrcnd.i or offcrcd lor qh. lt ho*.ts, rhc tuiuing or impmtmir h $kl *ithir .nc ru
<br />of.oDtlcriDn. rhc Osn r BuildLi Eill hlvc ltE h!(kn of nmvitrE rhd he or \tc did Rn hliU or inFms l}r fmBiy for rlE l]u'Ift ol
<br />La\owncr.rrhprcpcny...xclusilclyco.rrucrins*irhlicctrrdconrado^n,.on{rudrhcl,oid(Scc7014.Busircs
<br />a lhlL\siD Codc: 'l nc Comrucroii l-ic.n\c Lrw des nor apPly t, en osdd oflmncrlyBho huil.h or nlrruvcs rhrr.on.
<br />and who .onkdch ror ruch pojccrs with 0 Conrracbn, liccnrcd puruanr ro thc Coik,.ruis Li.cnsu ljw).
<br />I rNcxcnrfl uftrcrSccrion_
<br />]v0aEi8El;ollfEls rIaN
<br />DECI. NAIIA!
<br />I hcrchy nlfinn utrdcr ncnrllyotntriuryonc orrtf, nrk'wins d.chrdin\:
<br />-Ih.vcr
<br />willnrinhinaCcnificsrcofConsnlloSclllnsu,ciorsorkcr coinpcns.rir)n. !. povidcd lor lty Sccrn'n]7fi).trhc
<br />Labor Codc. lor thc n rfonMmc ol rhc wor( for which rhe pcnnir h ir\lcd
<br />-l
<br />havc snd *illnrinrai. sorkcG .ompc$ation iNurimc. $ rcrtutcd bySccri{,nl?(X)ofrhc lihor Cbdc. for thc lcrlhrmk--c ol
<br />llr wo* forwhi.hrhk p.nnit is hsuct Myworkctr coflrpcnsnlion insuroncc cuici u]d lx,lky DUn$o rc
<br />€xempf .
<br />Expnc\ -1
<br />l.cniiyrhar in rhcl).rnlrnEnccoflhc worl lor whichrhis Dcflnil i\ i\\td. t nrllnol onployany pct\)n in any manncr
<br />so sx' IEcolrE subi]ct to lh. rorkcr compcnslrn,n Ls\ orcslili,nrir. Md aBN rhat ii I stoukl lEco're shF.r k, rhc
<br />workc conDcnsoltun nDehi.ns ofSc.rion l70Oofrhc l-"h)r Gxlc.I shdi. lonhqirh com!ly wirh lh,c nfl,!i\i.ns
<br />lYARlllNc: Frilurc ro scur! workc( ompcnelioo cotcrasc is unls*rul, trnd ihall subi.d un cnlJ)lo)cr ro rinioal PenDlri\ adl
<br />civil fincs up ro onc hundrcd lhousnd douss l$loo-(xx)). in rddirn)n ro lh. cns ofcomFnsotion, d!tuses 3s proYidcd ror rhc
<br />:::::i4&:ffi:,* Eo w _
<br />rllIls[D_laNria(14f,
<br />DEIIII.EAIIA!
<br />I hcrhy arr6 rndfi r.n.x, of p.rjury rhal I !,n lienrn undcr rrcvision ofChapr.r I (..d'B..in8 qnh Selb. ?Olll, ofDivnion l
<br />of rhc Blsircss lnd Pmfcsiion! C.dd, ,nd my liccn€ i! in rull ldcc trrld cfral
<br />E GQ65o,1
<br />o,,", ' 8'L- ll .-n*,,']- Bc4
<br />q)N$IB!.CTQNUJ!DIN(;Ai!NS
<br />Ihcrchy lfiflnxndcr pcnllryoitcrjury rhll rhcrc h a c.nsrru.rion knding rlency ntr rhc Nilbrnnfuc ofrhc sork litr thirh rhi{ N.inir i.
<br />isslcd (Scc.:1097. Civ C.)
<br />kMcr's N.nrr
<br />-
<br />AIIII(ANI.DICLABAI]ON
<br />I hrcly afimr undcr pcnolry otp.riury onc orrhc r{,lk,sin! d(lnrdidrrl
<br />D.n$lirion PcrnilsAsbcslos Nolincrii().1;cdcral Rcsul{lions (l illc 40. Pd6)
<br />Rrgtrred lxnrrol Nohli.rrof
<br />_lcnifyrhrr rhc fcd.raltoguhnrN rcB dingn\h:s.\rcnNvrllrcnollllplicuhlcbrhhImFcr
<br />Edor,n,,, n,'",",,, *i,rn,i.ar6n drl s,r rhd rhc au)lc inhirnitbn t cotrc.i t d8rm rostrDly wirh allCilr rnd Counry
<br />onlnrNC\ rnd Srn.l r*s ru dins (, h'ltl[!.oinnr.r rcpescnrarivesof rhi\CirlandCounryloc crulsnltE
<br />ibotr nrcnliored nroE-rly r'or insp.crbn pt'rxNcs
<br />nppriconr or Acenr sigmr;re )4
<br />t,.mi,F w*(prir,): X- Ei6 C+^.,r.,
<br />Ihle :X'z-tg
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Satety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Bonding / Groundinq / 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 />Ceilinqs (Hard & Soffit Rouqh
<br />Ceilinqs (T-Bar Rouoh)
<br />It4eter Release )tj{dl>
<br />Rouoh
<br />Service lvleler
<br />FINAL 8 L1\\1 .r'.,t&.rlit )
<br />Notes, Remarks, Elc
<br />--)
<br />ELECTRICAL.INSPECTOR RECOHD
<br /><;-h-
<br />Under Slab / Floor
<br />7-3/lcr'
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