|
APPBOVALS DATE ID/SIG.COMMENTS OWNER BUILDEN DELCARNTION
<br />I hcrcby ,ffinn undfi Fnrky .f p.rjury rhnl I m .xcm0 fmrn rh. ContradoF Ltcns ti* for lhe following Etr$n (sR.ro-ll 5
<br />Busin.s .nd Proicssn r Codc) Any Ciry or Coutrty which rcquncs ! Ismn Io con(dcl alret, imrrov.. dcnblirh or rcpdit lny
<br />strudurc. pnor ro its ksuoncc, oho rcquncslhe atplicnnl r'or such pcrm b nlc ! si8rcd ilrcftfl rhd hcoi sh. n li.cnrd pursulnl
<br />r. rhc lrfovisb nfrlE Conro.br's LrcnRd tjw (ch.pr.r 9. ComincncinS pith Scclion ?OOO oI Divtt,n I orrhc ausi.css and
<br />Potusions Ckle) or lhll hc or shc i\ cxcmrr rhcrclrom on'i rl* blsh tu rhc aucscd.knPii.n Any viohtonofScclhnTo:t1.5 hylny
<br />aprlicanr t{, ! p.nnit suhjccrsrhc amli.a.r r. acivilpc.aliy.rn.r d.rcrhn fivc hundrcddollss(5500).
<br />l. Ns owncr ol lhc pmFny. or my enrployes wilh wascs r\ thcn vnc conrcn{rion. *ill do rh. worr .Jd rhc {dm i\ mr
<br />i .d.d or ofcred for \(lc (Ss ?(!-1. Brsincs and Pmicsbns Cod. The conrm.tofs Liccnt Liw doei nol upply ro !n owncrof
<br />rhcFn)rdy who hurldl or nl{,revsttuNn. cBl*ho dms such wnk hinscllor hc^clfor rhrough his or hcr own cmployccr.
<br />prrvi{lcd rhar soch nnlFr6rnh G mr idcMcd orofi.Erd hr ek ll ho*cvc.. rhc nliklin! .r impmvcmnr i\ $kl sirhin ncr
<br />ol onphrion, lh. Owncr ltuit+r trilliavc rhc horden ofpoins rhal hc o, \hc did fr, brikl or in{,ot fic pmFnt d lhc purF,c ot
<br />-1.
<br />!s ow.cr oI rhc !mp.,ry. am crclusitl, conrEcrins snh liccncd .ontddo* tu sn{D.l rtryroJ.tt (Scc 704,1. Bu\iNs
<br />od AolcssiD C{xle: Th. C6nrd.t sLi.cn\.tjqddsmrrmlyroatrowtrsofropcnyuk,tuildaorim ovcs thcreo.,
<br />rnd *ho.ontBdsforsuchpmJ,rtswilhaConlmch(nliccnsdpunudrr,rhcCo.tu.ror'sl,kcnscLoB).
<br />I dcr.nnr undc. Sccrpn . S & P.C. ir rhtr (a{.
<br />O*n.r:
<br />UOBXEEI-(AUIENSA.IION
<br />I}IILASAIIA!
<br />I hcrcbyrnnnundcr pc.rlr,olpcryuryonc ofrhc iollowiDs dccl rlions
<br />Ihf,veud*illroinrri,,aCcnillMrcolCon\ctrrroScllln\urcl.rworkcrs'clnrpc.sllion.!rp()!idcdrorhySccliotr:lT0Oolrhc
<br />li6or Codc.lorlhc pcrtorronccofrhc worl for*hichrhc Pcrmir is i\su.d.
<br />l hrvc rnd will
<br />'nainn'h
<br />*orkcrs .ompcn$ri insuntrrc.!s rc,luircd hrSccrion.l?01)ofrhc tibor Q)dc. for thc P. onunccoI
<br />rh. trrrk ro uhrh rhr Firntr rs F.rd Mv trorlcr,'.nmNrsr'on rn\u'rr.. t rIY J II,li', ndnhcrdc
<br />.,,., ll'.{,r'At b" :I-!rs-
<br />.\,\q-
<br />IIARNINC rnilurc ri r.trc $.rlrri coa,Fnrrri,rr .orc.r!. i\ ut xtt|. r d (hrl {rhll.r at c rd.}cr ro oiminrl ll(nalii\ rDn
<br />ro o.c hunnrcd rhon\{nd dolhr\ (Sl(X).(x[). in rddirion k' rhc.o( ol .o 'tc.\aridr. ditrrgcs ar p(ridcd for ihc
<br />Ssri,,r.1076 olrhc tahn (idc- i' crc{ rndrrtnrcr's nc\
<br />,,,,1[ga0J01&
<br />pEcl,aSeuo!
<br />Ih.Ebyaf6rnundcrF€naltyofpcrjlryiharI!nlien*d!.dcrpn)viionorCh.pr$9(cor.Ercitr8qnhScdion7000)ofDivisi.n.l
<br />ol rhc Busi'rcs(iM Pnnc\slonsCodc. a my licensc h n' tullfoeandellNr
<br />^%:lOotlb4
<br />AUG [, u /u !u,,,,,...,,,.ffte\
<br />co!fl8lgrmuiNDAc3iENLr
<br />I hcrcby lififln trndq lf,nrhtdrpcrjxry rhar rhcrc r a..nnd.rioi lc dir8 agcEy for rhc lErfomrcc ol rh€ work lor whi.h this |l nir i
<br />hsucd (S( .1097, Civ. C.).
<br />trndcr'sNam:
<br />APILIIANL.DE!:IIIM.IIQN
<br />I tErbt aninn undcr pcnahy of psrjlry 6ne oirhc lollosins decluarion\i
<br />Dc@lhi6n P.rmit-Asb.nos Notification Fcdcral Rc8!l.lions (I irlc.l0. Pan6)
<br />Rdtxiftd ktrcr.f Nolitu lion
<br />)4i(n,ry,hr r rrrr rcr,r,hr.,nf rrr ior ul($crhd rhc ihovc i i'r x i{ i\.odc.r lrgrcro.onfltwirhnllCiryannCounr,
<br />hortc rc]trcs.nrriivcs ofrhi\ Cil! rtrd C.udy l,i cnr.r ufl)nrh.
<br />rh^c Hnrnnrcd t()p.ny f(tr i'r!t..rii
<br />wG os .,!ll
<br />,\DDliutrl or \!Nl Sil]nnlu,r
<br />'\a.^t A fr'o ,\
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab i Floor
<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 & Soflit Rouqh
<br />Ceilings (T-Bar Rough)
<br />lVleter Release
<br />Rough xl2z4'o clat
<br />FINAL 7/41,*5\.f/
<br />Notes, Remarks, Etc
<br />ELECTRICAL.INSPECTOR RECORD
<br />Pole Bases
<br />Service [\ileter
<br />-l
<br />ccni,ylhol ir rhcF:rlormancc ol rhc work Lr which rhis pennn is ku.d.l shrll not c.Itloystry Pc6on inanytunncr
<br />$ Ak, tE oft sbj.d b rh. w.rkc( smp.nslion ldws ofcalituoi,..nd lerce rhar ifl \hould tr$ft subjcr ro rtE
<br />wo*c^ conp.ns,itun rovisions.ls.dion l7molrhc btrr C(lc.I shlll.l'odhwirhflnnply wnh rl*,t pn,vishns.
<br />_l ccnifyrhar rhc ndc rul rsn lar ionj dss'ding ,sh.sos ..mrf,l trrc nor lpt'lic0blc lo rhh pmrcl.
<br />----t---
<br />I
|