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APPROVALS DATE ID/SIG.COMMENTS OWNER BUII,DER DELCARA'TTON
<br />I hcrchy 0filirn unilcr tlcnalry ol r.rJUry rh.r I aln cxcmpl frorn rhc Conri0clon l,iccne Ij* in rhe folk,sinS rcrsntr (Sc..loll.5
<br />Busincss rnl Profcsion Co<lc): Any Cily or Counr, shich re{tlircs tr pcmir h .on{ru.r. akct. rmprovc, d.'nolish ot rcpnn !try
<br />{ocrurc. pri{,ro ir\ i\sro.c. also rcqune! rhc {di.rn' lnr \xch p.rnii b fiLx siSncd Mtmnr th0l hcor ch. is li.cn*d pur$3ii
<br />lo rhc pmvisions ol lhc cotrroctols Liccnrd Llw (Chnplcr 9. Con nch.'nrs $irh sc.rion 7(xn o{ Dilhion I oflh- Businc$ ond
<br />Pn,fc$iotrs (.odc) or llur tc or shc is cic'npl lhcrcftr,m4d lhc bs\is r rhcrllcSddcxcnlni,)n.Anyviol.lionofScclionT0:ll5hy3ny
<br />ntli.rnrror,Frnrir\uhic.Brhcntplic,nrro0civilpcnalryornornrrcrh0n,ivchundrcndollar\(S5iD)
<br />l. as owncr of rhc In,ttny. or nrt .nrthryccs wnh wlgci * lhcir $h .onfc"sd n)n. will do rhc $or\ rad rh {Mnh N k{
<br />i, cndcd orollcrcdlirrqnclss.7o1.1.l'lsincssatrdlrrolcsions(ixlc:-lhcci,nta(r.fsLiccnscl-i$do$norapplyb3nowncrof
<br />rhd pnIf,n, qlF huilds.r irqimvcs rhctonr aftl *h.dcssuchmrk him{lfor hc$clfoirh$u8hhis orlE osncnDkDccs.
<br />rrovnhd rh(r suci iryr ovcmnls m mr idEndcd or oftcEd ,or $le lt ho*c\s. rh. huildinS or irqrmvcnrtrl i! sh wnhin nm $nr
<br />otco'npLrt,n. rh. Oqmr Bniklcr willhrw rh. budr. ofptuvint rh, tt or $c dil d blild nr ilrprcvc lhc prcfrry for rlt Nqs{.f
<br />l.rso*r(rolrlrpr'|Eny.snrci.lusirlyconlraclinB*ilhlic.n\cdcoDrrt,^ro.o{ru.rrhcpmjccr(Scc7r}1J.Bu\incs
<br />,id l\di\si Codc: Thc Cotrtrcrofs Liccnsc tj* docs nor aptlyro atro$ncr ol pn'pcnywho build\ or imt(,vcs rhcrcoi.
<br />ond who.o mcF io. rch ro]cclr wirh a C.nrncrul t liccnscd nuNur ro rhc Conhcttr\ l-iccn* ti\r ).
<br />I dnrcrcmd undcr SNnon .ts 4PC lor lhis rcJ-,n
<br />D,ler Owner:
<br />woRxEns- c()MPtrNs noN
<br />DEIUAA.IION
<br />I hcrcby rfliifr undcr p.mtryol Flury onc olrhc folloairS d.rl{alioN
<br />-l
<br />hdlc ud sill nbinidi'r u Ccd ift,c of Cons.nt lo S.lt lnsuro lor workcn- compcnsri.n, !s polided lot by S*rion l70O of (lr
<br />Llbor Codc. li,r rhc prnor.Eice orlh. *ork for whi.h rhc l.nhn h hsucd
<br />I havc nnd will nritrriin {orkcrs coml}cn{l ion insurancc- N rcquird hy S(r nrn .l7tx) of rh. Lll{r Codc. Ior lhc psforDnc. of
<br />! rhhFrnri n nsucJ Myworlcri onrpctrlrlior nru'rn( canicfund fni.y nuntEr iuc
<br />OI
<br />-l
<br />ccnitylhnl in rhc pcrt)rnunc. ofrhc work tu whi.h rhn r.r.ir n issucd, I shnll nol cmtloy any pcrsoo in any ntuincr
<br />$ as!,brco s subjc.! uihc aorkcs conDcn{alion h*solcalirirnia. lntl asmrhar irl\hotld }rcom subid rorhc
<br />woricF.onurcnsllionDmvisionrolSdn'n:lTtuollhctltnrC{xlc.ldrll.lunh*irh.onulywirhrhoetmvisiors
<br />W RNINC: F.ilur t, rdcutu workc^ (lmNns i,,n covcrrpc rs u lnqlnl rnd nmll n,hjccr an cnrpk)r$ ro ri'niMl ltnrlias d
<br />civil nn.s p ro onc hond.d rhou\rnil dolldrs ($lm.Un),
<br />'n iddniotr l{r rhc cosl of.oDpcnsalion- drnEgc\ rs Provid.d fitrrhcI-#d clxk. i'lcrc{ rnd xu,triry's l.r\
<br />DECIdEAIION
<br />I hcrhy afirm undc! rcn{hy of ocrjuy lhar I sm lien$i lnder p,ovision nrChaptc.9 (onxrcmi.8 with Scclion 7(x)0) olDir(k,n l
<br />of (hc Burin.ss und Polcsiotrs Codc. ud my liccns n in tull iorcc und calecr
<br />,r.r., ?l
<br />T. LL F1U L,.1-1q s<{U;Ttd 6 tttutiz.o. t]"zry ]Yq
<br />raxslf,ucllaNrllDlNcllirM:I
<br />Ihcrc6ytrlltnu cr lrnrlry olpcrjuryrhd rhcrc i\ r.on{o.rion kidnrs rg.fl.y for rhc Friolnmncc olrhe *ork ft, thi.h rhn pcnnit t
<br />issucd (S.r.ll)97. Civ C.)
<br />APILIgANIDECI.AAAIION
<br />I holtry.ntm und.r p.mhy of pcriury one ollhe following dcclaalions:
<br />D€@liiion Prmns-Asb. os N.ti6c,tion F.dc6l RcSnl,rions (_tille 40. P.n6)
<br />-Rcqutcd
<br />Idlcr of Nolifr.lion
<br />-l
<br />e ify $ar rhe lcdcdl EBlhrions rg,rdin8 rstxstx rcmral dc not 0prlicublc lo this pmjccl.
<br />I sdily ttlar I haw esd rht applkolion od slarc th,t lhc abovc intomErion is corel. Lg6 lo .r,mply vilh 0ll Citt and Counl,
<br />ordin.m6 ,.d Sr(. llws Eldioe ro building constru.r ion, and hercby luttFtir rpE*d,rits 6f rhis Cny .nd Counly lo .ntl. opon rhc
<br />^,,1b]t4L^-P
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Founlains
<br />Siqns (monument)
<br />Life Satety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soflit Rouoh
<br />Ceilinqs (T-Bar Rouoh)
<br />Meter Release
<br />Rouqh
<br />Service Meter
<br />q fio/FINAL tf -&*I
<br />Notes, Remarks, Etc.
<br />ELECTRICAL-INSPECTOR RECORD
<br />Under Slab / Floor
<br />t4
<br />I
<br />T
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