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APPROVALS DATE ID/SIG.COMMENTS OWNER BUILT'ER DELCARATION
<br />I h.rcby rlrrm undcr pctrriy or lcrjury rhor I ah crenpr rrod rhc c()nrrtoF Liccns tiw for rhc lrlk,sing rcavni (Scc.?lr.ll5
<br />Busirr$ nnd Pmrc$ion Code): Atry Ciry or Counry *hich rcquircs a lrrnir ro co0ntuc'. alrd. imlnrc. dcnn,lth ,tr tunxn r ,
<br />nocrurc. ])'inlo ir* issum.c. *o r.qut.aihr iftlkanr lnr so.h p.mit ro flc{ \i8md {nrcmnt lhrl hc.r shc i\ lic.nrcd Putnranr
<br />ro lhc [ovisi,,ns of rh. Gr tuin\ l-i.riscd Inw (Chdprdr 9. C(nnnrn.lig wirh Scdt'n ?UD of Divisn,n 3 ol rhc Btrsir]css rnd '
<br />Ptuf.\\io.s Codc) or ,hal h. o! snc is crcm rh.rclnrand rhc hNi\ ror rtc rllcecd crunfnn,n Anyvn,hriorofSccri,nT(,11 5byrtry
<br />3ppli.ml forapcnnit subjd* rhc rrpli.anr t, a.i!ilpcnrlry.rnor nrrclh.n fivc hundrcd dollan (S500)
<br />I. ,r osn r ol lhc proFnr. or my cmplorrcs rnh waScs es lhcn sh comp.nurk,n, will do tu *trk ud rh€ llndm il N,l
<br />intn].d or .fta'.d tor slc ISE '7(!l4 Bu\iic$ aad I'roicsn,nr Codc Thc Cbntrncror's Liccns tiw docr nor {ply ro !tr ostur ol
<br />rhc InFny who huilds or in{'mrcs rh.mn. and *ho des s$h w..k hinsclf or hcr\claor rhhoBh his o. h.. osn c rnlnyccs.
<br />povidcd rhai such idpow'ft.h m nor id.od.d u ond f(n qlc. ll k'*rv.r. thc hiEing or irlll,n,kni t $U wirhin om ,td
<br />oronlklion. rhc Owmr Buildra will haE lhc tordcn o, ri('vins thal hc or shc did nn hrild or irotovc lhc pmp.ny for lh. purtrs ol
<br />-1.{sowncrofrhctrcpudr,r'ncr.hrivclycontu.rirgwirhliccn$d.onhclosl{'condnrcrrh€pnid(Sc.7014.Bt\inl\rdnd ftor.\\bn Codcr Tic Conrradoa\ l,iccn\c L!* docs nor ap,'ly ro mowncr orpruFdy vho huildr or in'ff.vc\ rhcrcon.
<br />.nd who .ontach r{n such Im,jcds wnh r Conrruck,( \) licenscd punlnnrt, rhc Conlrrtois Liccn\clrw)
<br />I rmr\dnDl uDJcr S..rr)
<br />D.1.. O*ncr
<br />WOR(FR.STt)MPEI\SAArcN
<br />IEIIAAAUIJN
<br />I hc.chy lll tn undcr Enalry of Dcriuly om ol rh. Irnh* ins dalarurinnr
<br />-l
<br />nnve ud will Mintain d Ccnii.src oa Con*nr lo Sell l nsu.c ri,r eorkc^ .onf.nsur t,n. as lnividL{ lor by Ssl ion .t7(r) of rhc
<br />Lubor Codc. lor thc Frfoiruocc ol lhc wo l'.'r rhicn lic ll.n.ir is issucd
<br />lh,v.,id willmdinr,in wo*o{ .ontcns,rion insura.... tr{ rcquncd hySsrion l7U)oIlhc ljbor Codc. nrrhc rdrdm,n.. ur
<br />rh. *ork tr{hichrhi\ pcmir is nsucd. Myworldi &,mFnsnrion insuinn.ccmic md tiricynumhcr N:
<br />ciiicr: 6VA4,r)
<br />o 2/
<br />-l
<br />ccni,i rhar in llE lcrlonna&t otrhc wo,k r'o. which lhis Fuir i iss!.d.1\hnll n.r ctr[loy (try pcrsD in trny n*n'ff
<br />nr \ h lrcoft sxhjc.r b rhc worlcr( .o.rFnsd n,n hw\ or Crlif(rni( r rrrcc rlN il I rlDuld trsnm {hicd brlf,
<br />urrkcr\' R,mrEnssrio. po i\n,ns of Skrn,n :1700 of rhe titrtr C,il.. I rhrll. fodhsirh oflrply wirh rbr frovisn,n\
<br />RNIN(;] Frilurc ro snrc sorlcnL compcnclrion covcrr8c t u!l.wl!l. and \hrll slhjccr ai .'npk,$r ro nir.iMl pcruhis and
<br />fincs up ro onc hundred lhouFand dolllrs (l9llt).(x)o). in {dnilion lo rhc co or.oilP.nsirn r drnm8es 0s Pmvilcd I{n rhc:::ilq+tr
<br />DECId8AIION
<br />I hcEby nln n undcr Fnally ol pcriury liar I arn liens.d undcr pmvision of Chdprcr 9 (om,rcmin8 with Sdion ?U)0) ot Dilnjoo l
<br />of rh. B$in.s ,nd Pmfcssioos Codc. anti my lic..s is in full lorcc n clldr.
<br />liccniccltrls: R
<br />,",. 1-fiT[
<br />caxflf,ucuaNrllDlNc-&cENtr
<br />IlrcEby,mfl,undq,cMltyofpcrjurytharthcr€is4consltuclionhdiigDCc..yrorrhcPcrlormlnNoarhcqo,ktorwhkhrhisp.miri.
<br />ksucd (S.c.1097, Civ C.).
<br />AI]LICANLDECI,ISAII9N
<br />I hs.by,lrhnu.dn p.nrlry olpcrjury om otthc follo{in8 dcchr ions
<br />De.Flirion Pernirs slidos Norilic.lion FcdcEl RcSuhrnns (Tirlc40. PM6)
<br />_Rcqnird L.trci of NorifMlioi
<br />-l
<br />ccdiiyrhd lhc federalrcEUlurion\ rcardiry trdrno\ rumval rft nor dnflrlblc to rhn proj.cr
<br />l..diryrhd I havc rcd rhis application n (arcllu drc rhovc itrnm ion i\ cotr .r I rlrs to.omdy wnh oll City und Coury
<br />odirjNcs d Srarc uws rcktins ro nuiuins co.nrucrion. ard hcrchy ulrlnrit ftprc*nidnx\ ofrh* Cirynnd countylo cnrcr rlx,n ihc
<br />rh^c nf,nri,
<br />'
<br />rl rn t,. J l,r i'ry,(ri,!i t,ur
<br />tnol*, -n"*, r,".r*. V\
<br />.>A.utr,LzJ'k
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Satety /Low Voltage
<br />F ire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilinqs (Hard & Sollit Rouqh
<br />Ceilings (T-Bar Rough)
<br />[/eter Release
<br />I
<br />Bough 1/offtx^..yHq/
<br />Service Meter tz/o5/r{ -&1tt)
<br />FINAL llnx /ra--.44 'u/ )
<br />Notes, Remarks, Etc
<br />ELECTRICAL.INSPECTOR RECORD
<br />Under Slab / Floor
<br />....-
<br />(y'.-"*"., $-
<br />Lcndcr'. Addes
<br />I
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