|
APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DI]LCARATION
<br />I hcreb, afirm undcr l,ctrllty of lcrjury rhar I m .r.n'nr frcnr tlE Conlo.ro6 l,iccns Li* for lhe folloqins rcu$n (S(.?oll.5
<br />ausincss ,nd Pmrcssion Cde): Any Ciry or Counry shi.h rcqun s r Fmir lo en{ru.r, alr.r, improvc, dc.hli\h or rcpan a!,
<br />{dcturc. Eior to irs LlsuN., also,€qriEr rhe lpplicmt for such Fmn to fiLasign d star.m rhal hc or sh. ic hc..sed ruBua.r
<br />ro rhc phvnioic ollhc Conlnclor's Liccnsc{ Irw (Chaflcr 9. Comrcncjns witi Sccrhtr ?OO0 of Divtion I of rhc gusi.c$ snd
<br />Pnfcssions Cod.) or rhsr tEor.hc h.rcryr rhcrcfrcor.trdrh. h$is for th. allc!.d . rc mpr ion AnyliolariorofS(rionTO:ll5hyan,
<br />{plicanl for a pcmil subjNls lh. applicnnr ro,cirilp€nrhyolnol nwe rhln l'rv. hlndr.n do -s($500)
<br />I. rr oemr .f lhd lrnF.r!. or ny cnplorcs wirh w.Ecs rs (h.i Rnc .onDcnsrr io6. will do rlr uork md rlt {tum i\ fin
<br />irlrRkn or ofrcrcd lor $lc ( Sd.70t4. Bxsi.es r.d Pr.tc$ioN Codcr 'l hc Coninclols Liccn* t w docs nol lPply to an owncr or
<br />rhcpNFny wh hilds 6r iryrorcs dxjmn. lnd who d6 slch w,lk himsclf or hcrelf orrhrooBh hi! shcro{n cnIk,}c8.
<br />J,i(,!ided rhar such inrrorcmnrsmm, irtcndcn or o ftcrd foi elc. l l tu,wM.rlE hildingor irymrcmnr is sld Nirhirorc rte
<br />ol cotr{'hion. th. ow..r auildcr will hrvc rh€ burden of pnvlns rhol hc or sh. did ml hild or impmrc dc pmFny for ilE puqn* ol
<br />-1.
<br />nso*rcror lnclllo|[ny. i,ncxclu\ilclt.onrdcring wilh liccnscdcontrocro^rocon(rud thc trejcct (Sc! 7t!l4, Lustric(
<br />trid lbrcsii Cdlc: 'l hc Contrrrols Licctrse Lrw docs tror rptly k, trn owndr orpr.pcny wh{r build\ or i'.pFvcs rhcrcoo.
<br />and Eho .o nds rrtr such projc.r sirh!Conhck(r liccnscd purui i0rhcCotrr..roir Liccn* tr*)
<br />-l
<br />lncrcnrnr unlcr sc.(mn .B &PC lorinisrcrn,n
<br />Dole: Orner
<br />rr)f,rlrN:r(,lttlitrAtroN
<br />DTII.AIAIION
<br />I hcrcby !all! undcr Fnllryofl*auryonc orrh. rdlowios dccl arions:
<br />_l har &d will 'Einllin a C.nifratc of con*m ro Sclf- lnsurc tu wtrk€c ompcostk'r. s D,Dvilcd for by Serion l?m oa trE
<br />Lrhor tuc. for lhc,,.rfmlm.lth. wor( Ior *hi.h th€ p.mil t issocd.
<br />1 havc a.d qill mrinrrin workcr' compensarion ins@tuc, ai eqltcd by secxon r7(D or th. kbor codc. ror trE psfornurc€ of
<br />lhc work for whth lhG p.mil is is$cd. lry wo*6s coqbsation insonnce cutr ad policy nuhbcr ml
<br />c,.n,llcd trl4€^t. ,t)
<br />5-i t 'r4 </ ta l19
<br />Iccnilyrhd irrh.pcrli,min c.ilhcBork tu wh hrhi\Ifnnir i\n{'o{|.Is lltror crployrtry ncron l.nny nMncr
<br />q, .(k,lf,om shjcd ro rhc *(trkc6 compctrs.iiofl hq(orcilitunria. (t l€to.Ihar ilI sh.uiJ hccom shJld l{,rll
<br />*o'kc^ con,Fnsrri,Dptr,vhionsoiSccrion.lTU)olrhctjhrrCi c. l shrl . tunhw irh .o rrlv wirh rho{ prcvi\ior
<br />WARNINO: lailu,c lo scurc workcs compcnsari.n covchsc i{ unlawrxl. md shlll rlbFcr an cmployrr ro oinioal rEMltis lnd
<br />.ivil fi6.{ up ro od hundrci rhousnd dolltrs (Sloo.om). ii sdd nin (' rh. cn{ or comnclerj!|. d,mgcr ai pmrided tor rhr
<br />S(rrcn nr76.l rhc lrn Gxic. inrc,c{ ! alormy\ fe.. , -Z--
<br />o,'", t t/zzf rl. ^*r*,,* {'( / ''' e
<br />LrclltEtLcottrtAcrrlBp&ct ASar&N
<br />I ltEby aflnn utrder Fnahy of !.rrury thol I m lic.nsd hd.r f,rcvisio. ol Chlptc, 9 (mmmrcinB Nilt Sation ?uJO) olDi"ision l
<br />of lnc Busircss and PolcsiorN codc.,nd ny lic.nsc is in tu|, tore andcfrNt.
<br />Li".n{"cl,.*,}t-aa
<br />u,r. n t/s zlr
<br />(]ONSI'RI]CTI(}N LENDING AGFNCY
<br />I hcFby aflirn undcr lcn{xy of Frjury rhar rh.e h . connddioo hndin8 sScncy fo! thc lerfornEm of rhc mrt for whkh thk rmir iq
<br />issucd (s(. lor7. ci!. c.).
<br />AIELIIANLDEII.Aa^.IjON
<br />ILnbydln und$ prnrlry.rp$jury oic orrhc rollowins dcladions:
<br />D.nn'lirn{ P.rnrir! ast no\ Norilicrrion lcdcralRcaulnrior lTirlc Llo. PM6)
<br />Rcqui'cd l-rrrcr.f Norilid i,n,
<br />_l ccrrify rhar thc fcdcml rcguhrions EgardinE (sbcsrN rcnDvolarc nol amlicublc lo this rrol€cr
<br />/ccdily rhll I hale rcud rhis arplicnrion ud srete th lh. rt I agre lo enDrryith srt cil, rnd counry
<br />o,{inr0.$ n.d surs Laws ElatinS ro b!ildin8 conchdior md hc,!b/ ru'hona rcprc<nldr$ ofrhh c y lnd counry to.nter uNn lh.
<br />,hoE mrrtumd nmlcn, for hsF-rron purnqarA .?
<br />noou,*r",ou",tr,,*>L.k /? o"," 6-zz -/ P.
<br />P.md,rn,m.(prr ,, *- a-Puts+l fotc'-
<br />Site-Work
<br />Unde rground
<br />Pole Bases
<br />S S Pool Fountains
<br />Lile Safety /Low Voltaqe
<br />fle Alarm i Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Rool To ul ment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilin S Hard & Soflit Rou h
<br />Meter Release
<br />Rough
<br />Service lvleter
<br />FINAL <,tso/l(5\84
<br />Remarks
<br />ELECTRICAL-INSPECTOR RECORD
<br />Landq " Addrc$
<br />Liqht Standards
<br />Siqns (monumenl)
<br />Bondino / Groundinq / UFER
<br />Ceilinqs (T-Bar Rouqh)
<br />Notes,EtC.
|