|
APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEL('ARAT'ION
<br />I her.bv aft m undd D.nahy ot pdiury lhal I m cxnpl to,n r& Cofl..clos Licds. Iiw for lh. lollosin8 r.Mn (Sa.?oll l .5
<br />Busines a.d Profsion Codc) Ahy Cny .r Conm, which rcqxirs a pssn to cobtrud, alld, imp.ov., donolist or r.pan any
<br />srructue rior ro irs isud... also r.qun6 lhe applic l lor such p€rmi lo ,il. . siSn i sraldn. that fic o! shc is li.oscd pu6ufi
<br />to the rrolisions oi tnc Conrrrcrofs Licdsd lrs (Ch!I)rd 9, Com..cins pith Sdion 7000 of Divi.ion I oalh. Busitrs ed
<br />Itofcsions Cod.) or rhar hc or sh. n.ronpt Ih6.nom Md lhc b6is lor lhc alLscd.rdflio.. A., violarion ots€clio.70ll 5 by dy
<br />ryplica aor a p.mit srbj..G lhc applicsol lo acivilpenallyornotmorclhm li!€ huf,dr€d dolldslt500).
<br />l. is ous orrh. rrop.nr. or ny .nplor8 *irh \ a86 s thct sle conp@lion. \ ill do lh. No,k 5d lh. s|n{1G is nor
<br />inlddcd oi o ITd.d for eL (Sd 7044. BusinBs d Profdions Codr: l lE Cont,ctoas Licm. t w &6 nol orply ro d o\w oa
<br />rh.pmFq sho toil6 or improv6 rhqan, dnd *llo dB $ch $od( hims.lf o, hGlf or rtmush his or hd oM.mployc6.
<br />provid.i ih.r strch inprcldnors mnol hlod.d ororq.d rd eh.Ii ho*66. rlrc buiklins or inllIo\Ed i! $ld$ithin.n.,@
<br />olcomplaion. $.6,a6 Btrildd willtllrc th. bud ofprovins lli4 h. or trh. did not build or improvc thcI)oFy 6r th. purporal
<br />I. s o$nq ofrhc popdy. m dclusiv;ly .omracr ins Mh li..6cd contaclou lo coNrucl rh. Foj.d (sd 704.1. B6ms
<br />and A!6snn Codr: Th. Conkacrois Lic.nsc L.w do6 nol applylo doNn6 olprurdry \vno builds o, impov€s thdon
<br />and Nho conkacts lor $ch r.ojcrs wnh a ConrEclo(s) li.e.sed puuuMt lo llrc Conlmcrois Lic6* I-aw)
<br />lan.\cnl! ond( secri{.n .lt &P( for(hisr(a\.tr
<br />Dri. (rrnrr
<br />llanr!8s:.caMruNlAf:l)!
<br />DECI,AIAIIA!
<br />I hdeby afllnn undq p€nahy olqsrury one olrhe aolloNing dNlararions
<br />Iharcandwillnai.i.rCdifical.ofcoMtloSclf-lnsur.loruoA6'comp.Nalion,6p.ovidcdforbysctiof,1700ofrh.
<br />l-rbor Cod., for rh. Faonnrnc. of tn. work ior whici ln. p6mi is isu.rt
<br />I hay. and Nill nainrain wo 6 conp.Barion i6uran.., s rcquned by Sclion 1700 oarh. Labor Cod.. lor lh. pdlomdcc ol
<br />thc {ork for r hich rhis p.mn is t$dl My wor*6 comFNI ion insur c. can( dd Foli.,nun$c a€l
<br />| 1-(A1e ?vt..JV
<br />"r"r"*,u,' lL6 lb01 zo tb l( -o( -z- \1
<br />I ceni& rhar in rh. ndaoman.c ofihc worl for which thh ponil is issu€d, I shall.or.mploy any lEsotr in any ftmnd
<br />e 6b hco,nc subjel lo lhr woltqs colnposarion laq3 ofc.lif.mia. md asre lhal itl should b.com.3ubjet b lhc
<br />qod6' compaetion provisios oa Sdlion I700 oarhc L.lltr ('ode I sh.ll. fonhvilh conply wnh tho* provisions..
<br />WARI\INCT F.ilur.lo sur. sorkm codFnsaion covdsc i3 nnl,saul. d shall subjdt d ftployr ro aiminal p<Ehi6 and
<br />.nil fincs up ro on. hundrrd thoMd dollm ($100.000). in addnion b the con ofcomp.nelion, dmagd s prorid.d for th.
<br />Sdion 1076 oathe kbor Codc inlr6l dd dnoney s lB
<br />n*e: -L|LLILLZe\L &cnan,,9 fr,{tie aoo
<br />tlCElStArCOtlllACIaa
<br />DECI.ATAIIg!
<br />I lEEb, lftuo ond6 paall, of psjury lhal I o licqsed urdi Fosioi of Chapl6 9 (conhdcins sth sdion 7000) oa Division I
<br />of lnc BNin6s dd Prol6sioG Code, dd ny liccM is in tull forcc md efccr
<br />,".*. a,.* " P
<br />o^"' lz/t+/tot$
<br />I icarP Nu'ntrr \s zqqo
<br />c*"*..,!A ,Iu Joo
<br />CQNiIBlJCIlOIi.tEIDllCrICTN.cl
<br />I hq.by rfilrm unde !6rh! oa pdju!,v lhal lhac is a coNrruclioo hndin8 .8ncy for ln. pqfomdcc ol lh. Mrk for Rhich lhis pqmit is
<br />issucd(Scc l0!?. Civ ( )
<br />4IILICA.ULIIC!,Af,AIJON
<br />I hctby afl'm uida po6hy of pdjury on. ol th. aollowinB ddla.doos:
<br />D.molilion Pmils-AsbBros Norincarion F.ddal Rqllsiiors (Till€ 40. Pan6)
<br />-R.qunal Lard of Noti6.rion
<br />I cGlify lhar lh. f.ddal r.sulations cg&di.s 6b6ros ronoval d. not applicablc Io lfiG prcjdl.
<br />Zl c€lily rfiar I have Esd rh6 appli..rion ed siare thar ih. .bov. intom.lion
<br />'s
<br />.od..l I agrc lo conply wilh all Cily Md Co@ly
<br />ordimc6 d Srar€ t vs rcl,li.s ro buildins .on$ocriod rnd hd.by auhonzt r.F€stari!6 oflnir Cny d Counly lo dl6 lIFn lhe
<br />ahv.,hcnrioncd prep€ny for insp..lion purr{s6
<br />ADplici l or gc l Signnllre:
<br />t*rr* ,"," rpano, F- lTirA Yr/ J.: o
<br />,,,. t \7f 17! >ot.$
<br />Site-Work
<br />Underground
<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 />[Jnder Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)/ -:'le
<br />Ceilings (Hard & Soffit Rough w
<br />Ceilings (T-Bar Rough)
<br />Meter Release
<br />Rough
<br />Service Meter
<br />FINAL 6-A*n VI
<br />Notes, Remarks, Etc u '\_/
<br />-t
<br />ELECTRICAL-INSPECTOR RECORD
<br />/ .r\
<br />\r',vJ1il)
<br />h\'
|