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APPROVALS DATE ID/SIG.OWNER BU!LDER DELCARAIION
<br />I lErchy amnn undcr pcnahy or p.rury lhal I dn cx.'nfl rionr rhc Contrudm Ltcns ti* ior rhc lollowi,E r.,y,n (S( 7).ll 5
<br />Br\ines and Proic$ion Codc) An, Cny or County whi.h $quirs , F,nir b ..nerucl, alt.,. in[rcvc. dcnFlish or rl)a iny iru.tun. Ei{trlo i( issuancc. aho rcqui.es thc lnllica for su.h p.iinn b fihd signcd s,r.'mnr thsr h.or shc n li.cnscd tllrsunnr
<br />lo lhc prolhn N ollh. ContBcrors Li...s.d Law (Chrprcr 9. Commcncins wiln Scction ?()Otr ol Division 3 olrhc BnsircN rnd
<br />Prorcs\ions Codc) or rhlt hc or shc n cxcnrpt ihcrcfrom r(! $c basir fu rhc alkacd.xcdprio. Any viol.rionofSdionT0.ll.5 byony
<br />amli.a rnr a p.,nrir luhrccls thc amliqnr to acivilpcoallyornor imrclh,n 6v. hundr.d dolh6($5ff))
<br />l. as osmrolrhc rop€ny. or mycmplorccs *irh w.Bca ns rhcir $lc dnnpcnrdion. williL rhe *ork srt ihc dtuN is mr
<br />idcndcd troficr r(r saL (sN.7044. Businc* md Poicsst,ns C.<lc 'lhc Conrrucrof s l-iccnsc L.w docs mt aprly h nn o$rcr of
<br />lhcln,pcny sh, i&ilds o, irymvcs lhcmn. ind who nes such wo* hinsclfor turcllor Ihn,rgh his or hcr own enplotcc\.
<br />Ptovided rhflr slch inpmw.Enls I ml intc cd orollosl Lr eL.Il hosdE.lh. h{ilding or ifithEtunr irsldwithrnnnc tlu
<br />of a.qrLrF( ttr o*nn Boildcr will hlle rht hurdrn ol pnNins rh.r lE or shc dil mt tDild or nryoE lh. pm,sry for rL purtss or
<br />-1.
<br />rs owner ol rh. l,otl.ny. an .xclusivcly .onrncr irs ]irh li.dird conrr{bF t' .on{rucl thc p(+{r (Sa 7(lr'1. tsusnc$
<br />dnd PDf6si, Codcr thc Conlmclois l-iccnsc L.w d.cs nor,pfly ro ri oricr olropcnt *hi, boikl\ or impr.,vcs rh.r.on,dod who .ontrcls [q such pn,jccrswirh r Conrrn kls) licnscd puNu.nl lorhcCotuacror's t-iccnsc lf,w)
<br />I har rnd sillmrinr.in workcrc conrpctrsdiotr in\utui.c, rr rrqxtcdbr,s(rn,n.1700or'hc,ihora)dc.forrhcpcraornrlnucoi
<br />rhc work rbr which lhn p.rnrit is tsu.d. M y workcr enl.n\rrn'n insrrnncc cm icLwt Flicy numhcr Drc:
<br />'r^lL
<br />Jnt,,rre'.q T..vgl l,alnIo7
<br />l..nfy rhlr in thc f'rrfontuncc ofrhc w.rk for which rhh r.rmir k is\u.{, I \hall.or.nploy 3ny pcro. in any manmr
<br />$ aslo bcconr subj$r lo thc workc( omFtrsati.n lr*\ ofCrlil{nir- !M a8rcc ihrr ill should hc(rE subJc.t to thc
<br />wolkcr coDrpctrsriiontmvsn, .rs.crn lT00orrhcLfitrCodc.lshall.nnlhwirhc.mplywithrnoEprovisions
<br />WARNING Frilurc ti $curc $orkc^'
<br />.iv'l fincs up n, onc hunnr.d lh.uv.d
<br />Sc.rmn 1076 ofrh. trhn G)dc. inr.E(
<br />mmncnsalion .ov.ag. is unldwrul. .nd shtrll sxbj$r an .mrloyrr ro sininal FMhts and
<br />dollr^ (Sloo.sjor, h additio. ro rnc con ol .o'np.nsarion, danugcs as Fovidcd ror rhc
<br />rnd b omv ! 1..!
<br />^,,,*,' s3l"r"'4'Vt+D
<br />Ll![!,rEDioNrtacraa
<br />DICIAAJIION
<br />aTlq) lb
<br />I heEby affirm lndcr pcmlrt of prjury rh l 0m lic..$d undcr pmvisio ol Chdprcr 9 (.ofrtutuins with S*rion ?Om) of Divhion 3
<br />ol lhe Burincs rnd Pmrcsio.s Codc,
<br />"Jld
<br />ny ltc.sc n in ,uU fore dd cfitrr.
<br />$
<br />,*" t:tTg2fq
<br />coNiralcu(rlt!lrutc-ari.Etcr
<br />I hcrcby a0irn utrdc. pcnlxy oa !.rju.y lhd lh.rc i\ i ondrucri,n lc.dins ascmy for rhc pedororcc of thc ,ork for Nnich thh lEmil is
<br />hsucd (Sc.1097, Civ. c.).
<br />AfIIICANLDECI.Af,AIIO!
<br />I horhy .ftim und( Fnalry or r.rjury orc oI rhc rouos inB d(hrur ions:
<br />Dcmhion Ponik-]\.b.{os Norifi.drion Rdcral Rcsulst ions Onb 4(l, Pan6)
<br />-Reqnircd
<br />kncr of Norin.alion
<br />_l c.nifyrhdl Ihc fcdcrllrcphrtuns rulrdnrg xsbr{os rcn$rrl !E nor aprlic.hle ro lth proFcr
<br />-l
<br />ccdifyrhar I h,k fud rhh applicarion snd srarerhd rlE Fvc inform.rion is.orer I 08rs b .ompl, *irh all Cny 8nd C.rfly
<br />..dinorc.s.nd sl,r. tjws El,rins lo buildinE consrdcrion. llld hcrcby aul horizc icprcstrl.tivcs olthn Cny.nd Counryro.nrcr up.n rlr
<br />x,vc nrnrn,n.d prcpcnyiff irNpccr
<br />l\pplica,l or A(cnl SiErntrr.9l{lwr.t wT?E-
<br />qlo:(ro
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Translormers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rough) I Itsllv 12 ry/4-dvt \--
<br />Rough
<br />Service lvleter
<br />FINAL 8/oz/r*l7r*rh /o\
<br />Notes, Remarks, Elc.
<br />ELECTRICAL-INSPECTOR RECOBD
<br />COMMENTS
<br />I an ex.6fl undcr Sdrion- A & P.C. fo. lh( rc,son.
<br />D.l. Owr.
<br />roBtrESS:tOMIB&Utll!
<br />DECLTBA.UAN
<br />I hcrcby atlirm under p€nalty oI p€rjury onc of lhc following dcclmrionsl
<br />_l haveuiwill mintain r C.difical. ofcon*m '. Self,l.s!rc for sorkqi comtEnsation, $ pmvidcd for by Secrion l?0o ofrtu
<br />tjbor Cod., ir lht pcrloMc of rh. $nk tor which thc Fcmir t issucd.
<br />g?o7of
<br />l,xtt b""*rr^o*l G.p
<br />lvleter Release
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