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APPROVALS DATE IDiSIG.
<br />Site-Work Z;)
<br />A,t*/t?Underqround ilrrln r,t't?t/r-4o
<br />Pole Bases ll 2t
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Torqueino
<br />Sub-Panels
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soflit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />Meter Release
<br />Rouqh
<br />Service [\/eter
<br />FINAL f lil ltr t\u-,rrXlP
<br />Notes, Remarks, Etc
<br />OWNER AULDER DELCARATION
<br />I hcrchy afifl. undcr p.nally (,f p.rjrry rhir I an er.infl ron lhc Conki.to^ Lacnsc Ij* for the lolouiry rcN,n (Scc7o:ll5
<br />Burncts .nd Piofcrsn clxi.): Any Cirt or counry whi.h nqut s , IEflrir to c-nsrruc1. 0lrcr. inprovc. dcn,lish o. rpm My
<br />socrurc.,rrior ro ns nsuancc. also rcquircs lhcnppli.nnt ior such p(rmit lo olc, sistrcd {dcftnr rhar h.6r sh. n lic.nscd Nrsusnt
<br />k' rhc pmvtn,ns olrhc G,nrr,.ror l-i..ns.d l-as (Ch,plrr 9. C.n r ing wirh Scdion 7utu oi Divisiotr 3 ofrh. Busincs lnd
<br />Prof.r\io rCod.){rrhd trorshc k cxcrhpt thcnlmnand rhc brsn idrhc {llcScd crenrtrion. Any viohrinnofS<rkn70ll5 by rny
<br />0!pli.a.i r.r r p.nnii subjer rhc omlictrtrl ro rciviltcnrhyofmr nlorerhln r_re huodrcddollars(S5m)
<br />l. rr osrcr ur rhc pnrp.rly, or my cmployccs wilh sltes ns $rn q,k mmtcnun)n, sill do lhc s ork and lh. \rtulm n nor
<br />i e.dal or ofcr.d ror $lc ( SN 704,1. Businc$ and Pmlcsiotrs Cdc Thc Conrra.l{tr\ I -tcny I i* dft\ nor 0prry ro .n oNncr ol
<br />rhctmlrny wkl boilil|.r nr{m,w\ rlrrs.. rxl who &{s s&h w.r* hnNcll.r h..rlfor rhouAh his or h.r own.frployccs.
<br />nrovidcd rh.t such nEorc.rnls @ nol inlcnd.n or ollcrcn lor strlc lt ho*ctr, rhc hu ildin3 d itrDrcrcrRnl is sU s iriin m )t r
<br />oroftpkri'n, rtr o*n.r BuikLr sill haE ri. t ,i.n ol pmvinS lhu rE or shc did trot huild or in{'orc lhc F,rrny r.r rhc pDITn{ ol
<br />L N o{ncr or rhc flDcdy, m .x.tusnrly onrd.rinS wirh li..n\cd cofiacrrs lo coNrucr rtc pojccr lse 7041. Bu\inc$
<br />ind Pirl$sion aodc ThcContrucln!LicenscLcwdoc\notrpplyroanosn.rotp.opcnywhohuildsorimprovcsrhercon.tr sho mnrBch ritr $.h prcixts wirh a Conrh.b(n li.cn\.d lusu,tr' ro rh. Conlnctols Liccne I!*)
<br />I rmcrrn,rr ridcr SNrioi B & P( lnrrhisrcin r.
<br />D.re: oemr:
<br />lonxonir-otuPr'nrs,rrrrrr
<br />DECI/AA.IIgN
<br />I hcrcby rfllrmundc. |xn y oi Dcriury orc of lhc f{nbw inE dNltrorionsl
<br />I hrw .rld will frridtdn a Ccnifictrrc of Con$trl tu Sclf.lnsurc for wor*c6 omFnsrrion. as F.vid.d for by S(rion l70O ol lhc
<br />bb.r C.dc, ror rhc FrtorMce oflhc rort lor which thc pdmn is hsucd.
<br />-l
<br />hovc and will mainhin wortcc c.r,pcnsrr ion insurarcc. N .cquircJ by sNi 6n rT{D trh. tibot Codc,lor thc perlormncc of
<br />rhc wor( forwhichlhn pcfl.ir i\ is\ucd. M,sorkers c.'npcnsrrion instrrutuc.rricr Md p.lf,ynumh..dc:
<br />Policy Numbcr:-ErpiEs:
<br />_l cenily rhal in rhc F.rlornukd ofrhc *ork ror which rhis pcrn,i i nsucd. I sh.ll nor cflrploy any pcson in !n, hanncr
<br />so .sIo h.{onE subjc.r ro rhc w{*cr orycns iotr hss ol Coliionrir. lnd lgreerhar ifl snouu bc&.r stbixl lol
<br />wo*cr'smp.nsorionprolision.olSccrionlTlx)ofrhcl,t$rC.dc.lsh,ll-ronhwnh.omdywirhrh.slnrvisions
<br />WIRNIN(l I: i,,. i) $. '. trr'lc,s (ru ovcftsc ( unl,wtul. ood sh!I {,hi.d , dlll) ora, ni .' mnrl t{ rl{tr\ nl
<br />.l .on,Nn\11i,r. ,lrfnld\ x\ Ird (i(Ll lor rh(civil fin.\ u! ro oft hundrcd rhousrnd d(($l(x).0(x)). nr.d irmn ro lhc
<br />s.!ti.n 1o7a nrrh. I*.r ('riL
<br />"",. s ll't ht
<br />r)1,( r \R\lx)\
<br />I hcrcby {itr un cr pcmlryof rrj cr pnivi\iotrof(hrfr.r 9rco'nntnci'rg sirlr Sc.rion TUIrrol Divilitnr 3
<br />ol rh.llurnc\ rtrd ltolr$nn\ ((!d.. u ry lirc rc i\ ll llnfurn clrr.r
<br />(-ro /zt{qt
<br />5 /s / tr
<br />I hrrhy rfid Dndcr jxnnlryorpcrjury
<br />nn'.d lscc.:r0o7. Civ C )
<br />..nnflcrnr lcrldir8 rgcncy lhr rh. lcrl'onuNc ofrhcwork hr trhi.hrhh Fni n
<br />Lcndcrs Addrcss
<br />-dIL(AILDIUIIBAIION
<br />I hcRttrlnm!nd.r lcnrlrt ofr(rpry onc ofrhc f(,lk,wn,! d.clrrrrtnr\
<br />l)cntliri{in l'cnnit\ Ast[slo\ Nori,lcrri,'n Ird{l.rJl Rrsuhri{nrs l'l irl. .{). l'rd6)
<br />rn,l Coun(!n) c r( uJ!irlir
<br />-Rcquncd
<br />Lcrrer ol Notificarirn
<br />-t{,niry
<br />ry't* tcd"^t
<br />^gubrion\
<br />(E$'iins shc{n. rnr*rlsrc mr sntlrrbh ro !hr Fm|cr.
<br />,.mLf t* *, ** ,rrtrJrbn arn r cth.r rh. at$v. ,nromr Fn scoffit I lprehcomrry
<br />ordmrm. rxs,,rc Lrs(rel,rtrg roburld,n8 c^nstrudbn. md harcb, su6ori^ EFrcscnraur.. nf,hN Ciry
<br />!r-vc mtrrnlt,oFny ror m.wro.,to.*/
<br />".-n*,*",0/,,, A,l,r- \fo\.,.,.t
<br />^
<br />8/rs/r,
<br />ELECTRICAL.INSPECTOR RECORD
<br />COMMENTS
<br />Transformers
<br />Air Conditioners
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