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APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DILCARATION
<br />I hcr.b, sffirm undcr pcnally oa p€rj!ry rhar I d c&n{,| rrom rh. Conhctm Liens L{* for rhc a.lLwinB rcas. (Scc 70ll 5.
<br />Busines md Profc$ioo Codc)r Any Ciry .r Counry which i.qurcs ! !.t,ril lo consrtocr. ,lr.r. nnProv., dcmlhh or EPlt a.y
<br />srdcrlre- pri{n ro irs hs"!ftc, d$ rcquir.s $c applk,nr lor suchF nli,lile t \is.cd nar.ftnl rhar hcorshc h licen\cd IUnu r
<br />to thc pnvhiotrs oflhc Conlreclols l,icrnrdd lf,w (Chrflo 9, Com,rcn.nrs wilh Secrion 70fl1 or Divkion:l ol rhc Dusirrc$ $d,
<br />Prntssions Codc) or rhar h. or shc is.x.nDl thcrclro ondlhchlshforrheallcrcdcftmprion AnyviolorionolSccrionT0ll5bydny
<br />rppli..dloraF.nnilslbjahrtcappliclmbacivil!.nnhyolnotnoerhanivchundtcddollaB($5Or).
<br />-l-
<br />as owm, oa rh. ptuFny, or nry cf,lrotes *iln q!8cs ur lhct sL o,nFi\ar mn. $ix do thc { ork &n lhc {er@ i\ nn
<br />inrcrdrd or drrrd ror elc (Sa 704,4. Ausinc$ ind Profcsirns Codc Th. Conrrttrt Liene kw der nor apr,ly r. nn owncr ol
<br />th. Fopcay sho tJuilds or itr{ftws rlris6. rnd who dms skh m* hnnsclfor her{lfor rhmugh hh or hftown cmplo)acs,
<br />tllov cdlh such irrymlctrcnrs@ mr inrcrd.d oorlcri itrsL.lf. hou.w( rh. ttriklir8 or innDvcmni k$Ll within.nc )ur
<br />ol cofttLxbn, rlr osncr Buil(hl uill haE lh. hodctr ol pn'vins lhr hc .r \h. dll nor build or imporc the PmFly Lt rhc purFrc or
<br />-l-
<br />aso*mr ofrhc pmFny. dmcr.lrsikly.onrddin8 wirh li.cnsd conrrlckns lo coniru.r rh. pmid lSLr. ?OlJ. Bu\incs
<br />dJrl BJKii Codc: The Conkacutr s Liccnsc,i*dms nor trpplyro rnownc.oiPror.nywho buid\o, inprcv.sthcrcotr.
<br />and sho co.a.Lforsuchfmr.Iswilh!c4nrado(,liccnscdpurlanrbrh.a,n0&roasLiansctrs)
<br />I an.kcnrpr undcr Sdio
<br />uaf,f,E&rlollEENs rlo!
<br />D[CI/36.IIA!
<br />I hcrchy lmnn uMcr penalry of pcrj!ry orc ofihc f{,llouint ddlardions:
<br />I hrv.d will mrimair 0 Ccnificorc ol Consenr t, sclf tnsrt r{, sorkds .omFtrsotion, as pmviddd tur by scr ion ]7(x) o l lhc
<br />ti&tr c( ., ru rhc rcrronMncc olihc *nll lor wnich lhc Nrnn n isucd.
<br />{t m'" una *itt .oin,nin *nrlcs ..mr.nsrtion insunRc. ri r.quiFd h} Sal ion :1700 or rhc bbor Code. for lh. pdiotucc of
<br />rhc *ork ld shich rhhrxiinir i\ h\md. My qorkctr- comFtr$riotr in{.ancccrrirr fllrnicy inn$cr nc
<br />-l
<br />ccnily rhtrr i. rhc,Errortu tc orlhc work ror uhi.h lIis fcrnrir is is\ucJ. I \h]ll n.r cmploy rtry neNon in nn, mann.r
<br />$ k, trroN suhjNl ro lhc wo*cs'conDcnsr'ion uw\ orcrllr(rnil,M a8tot lhal il I shoukl bcco,* subic.r ro rhc
<br />work.^' .o'nNtrs.rion povhions ol Sccrn,n :l7m of rhc llhtr Cod.. I sh,ll, lon hwili onPl, {i(h rho* F,visio s.
<br />WARNIN(; lrilurc to Ecurc wortc conrpcn$rion colcrrgc is unh$ful. rnd shlll$hlc.r rn dnlPbtt. u diminrlPcnnti.s !!,1
<br />.ivil fin.\ u! ro onc hundrcd thou\and dolla6 {$IoO,fi)O). in addtrion ro lhc co{ ol co,nP.n. d,nDE s es !rcvncd rm rhc
<br />S..ii.tr !l)76.r th.Ilhar Codc i' crcn
<br />"nd
<br />atrorm! \ fccs
<br />g1 [0 ]lor0rt n,,o*,
<br />DECIjBAIION
<br />I heEbyamrnundd p€nalry ut p.rixry lhll I am liclnsn uMcr Pmvisioo ot Chapid 9l.ommncinS wilh Sation l00O) orDivision l
<br />oi lhc Ausircss and Prcfc$io.s Cod.. .Jt ny Iiccns is in lull lorcc an cf6r
<br />I I
<br />na G1l"'0l$ -"**.
<br />CONSTRUCTION LENUNG A(:FN(:Y
<br />I hcrcby nflnm undcr l.ulryofrxiurylhlt lhcrc is a.olr(rudion lcff]i.g a8c..y br rhc pfllnrmncc or ric aorl for whah rhis rernril h
<br />ksucd (Sec. 1097,Ci!. C.)
<br />A.BITCAILDICLABAIION
<br />I tmby lnirm ullcd ,l.nolry or o..rtr.y onc or rh. followine dclr ions:
<br />Dcmnnio6 Pcrmik-Ashc os Nolificalion Fcdcrol Rc$lrrions (Tnb40. Pan6)
<br />Rcqun.d lrrlcr oi Nolifrnlion
<br />-l
<br />edilyrhlr thc fcdeElEgul{io.s rcsrdins a.b. os Emvnl u€ nol aff'licabk t rhk pmid
<br />ItLl dn 'ry rhr I havc rcad rht onplrar ion ajd nsr hd lhc !tr!c inromrn,. k comct I .E@ ro @q,1, wirh dl city rnd Counry
<br />ordinaiccs rnd Srsrc tissrl itrr b huili ir8 .onsrrucr i{u nl hclcby rc[csctrhtives ofrhh Cily rnd Cuu.tyto.trrd ulx)nllE
<br />rliorc rNtrrioncd rroncny nr inrncd
<br />,\ptliu l rr,\A( t SiAnrlure
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor ,']
<br />Bonding / Grounding / UFER Y-21-tK i
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Boof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduil)
<br />Walls (Rouqh)
<br />Ceilinos (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />/A
<br />Rouqh 'da)+A_tt-21- ty )
<br />Service Meter
<br />FINAL {-2t-/y k-
<br />Notes, Remarks, Etc
<br />ELECTRICAL.INSPECTOR RECORD
<br />r.lUtlt
<br />lVleter Release
<br />l^,,1 *olQ
<br />tFd.ir NJtr
<br />-
<br />{tr+r +o
<br />*,. oe (o) 1olot8
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