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APPROVALS DATE ID/SIG.COMMENTS OWNEI BUTLDER DELCARATION
<br />I hcrcby aflt'n undcr !.n.lry of pcrjury lhal I m cx.mFr fto,h lh. Conr0cro^ Licctr* tiw lor Ih. lollowiDs Essn (Ss.?oll.5
<br />Blsinc$ nnd Profc$ion Codc): Any Cily o! Couflly *hich rcquncs , pcnnil to on(rud. !lis, improlc. d.mohh or EIun lny
<br />rrtucru.c. p,itr lo ns issuane- al$ rcqut$ rhc op,rlicnnl lor sucn lErmit h filc ! si8n d slur.mtrl rhnr lE or shc is liccnscd ,)urslnl
<br />ro lh. [ovisions oflt Conlra.toCs Li.c.ed t2w (Chap(cr 9, Commcftiig wnh Sc.li.n 7urc of Div,sion ] oflh. Busiftss ind
<br />Polcsions Conc) or lhd hc or shc is cxcmpl lhcrcto'n lnd $c basn lo1 lhc lllcScd crenprion Atry viol0tiotrofSElhn'7031.5 byrn,
<br />apdillnr .lr a pcmir lubrccrs lhc lpnlicanr lo acivilpcnaltyofml mrc thln fivc hlndrcd dollusl$500)
<br />_1. !s owncr of rhc ImrEny. o. my cmtloycc\ *ith wa8cs as rh.i $lc onllc.sar ion- will d. rlE *ork 0.d tlE srtrrr is mr
<br />inr.*icrl oron r.d,or sk ISe 70lt, Buiin s. dd Pmf.ssionc Cod€: Tlr Conrrlcrois Lien{ ttrw des ml ,I)nly tu s owtur of
<br />rhc pDncny wh. ttrills tr in{,rowr lhcmn. {i sho des ssh po* himsclfor hcrclf or thmuBh his or hcr o*tr cmploy.cs.
<br />Fovidcd rhor ruch inll,msmnB m Ni inkd.d or oft nrl for slc la tssw, ttE t ilding or inimwnEnr h sB rnhin oft )r,
<br />or compbrioo. rhc Osrcr Builds will hne fic tedcn oflnvin8 lhd lE or shc dil ml ttuild or irym( $c lmFny fo. llE lurrnc ot
<br />l. nsow.droathc pmpcny. rnciclu\ivclyconrrucrin8 wilh licenscd conrract os ro @ n srrucr rtr pmFcr (Scc ?044. BurNrs
<br />ond Pn isir Codc: Th. confurn s Liccnsc I*r docs nor rpplr ro.6ownc. of[opcny who builds or imtruw. rhcrcon.ond who.onrnr\fttr\u.hfotL{hwirhdcoirEcrons)liccnsdrrBurnrbrheconh.r.r'\l-i.cnscbw).
<br />I mr cx.nrpr undcr Set
<br />.uaBrErrralllltlr -II9NI2tr!L NAI]ON
<br />I hcrchy lln rtrn .r |xnrlryof p.rJrrronool lhc lnlkNiDg J.rlrrrrions
<br />Ihxvcdd$ill'ni'IrhrCcnilicarcolConscnrbScll:ltrsurcn,r{ukc6.onI.nsnrion.rs F)rid.dnnbyS..rio lT00ofrhc
<br />ljtJor Codc- lorlhc pcrri,rnEtrccofrhc sork inwhich rhc |[nnn n hsucd
<br />,/hrv.rndwilltr ntrinsortc^.of,pctrsn,ninsxtun(.arrcqundbys..rionlT0OoflhcljborCodc,furlhctclfoiinrn.cof
<br />work ior whi.hrhir t'cnnn n isseid M,wor*cK .onrrcnsarion insur.mc c,ricr Md ,$licy nun$cr N:
<br />1 t t
<br />t
<br />,l cenily lh.l h rhc !.rlornsncc ofrh. work lor whi.h lht l.rnnr is tsucd. I shall nor cmplo, lny pcrson in aDy moncr
<br />$ ,s t, b..rnm srhrccr ro rhc eortcd onrcn\a! ion lnw\ ol Calilhrni!- aad rCrc rhd if I rtsuld h..om srhJ.tr ro rhc
<br />work.s.o'np.trsrriohpr,!tn)n\ofSccrionl7IDofth.ljlbrCod..l\hall.fonhwnh..nrrlywirhrhostovismn(
<br />W RNINC I'rilurc b srue rolkcm <nnpcn{rion cuvcngc i\ unhwrul sh0ll \u$rd cn{'lr
<br />civil lincs u! ro otrc hu.dr.d rhousrnd dollaB ($lm.lxn). in &ddirion ro rhc co( oI comlxns.r
<br />S(rion lu76 ol rtE ljhr Gxlc. ir crcq and rr
<br />,",", 'fU 1,,.16 ltott ^,,ttrtiv 4
<br />r.(ilsru trnrn,rirrrr
<br />DECI.ABAI]ON
<br />I h€Eby atlird undd rc..lryofperjlry rhll I rm licnsd undr Imyision ofChaDrf 9 (@'mrci.s wirh Sccrhn TIIll).fDivision l
<br />of lhc Busimss and Pmfcssions Codc, B.d my licensc is in 6ill foe ard cfrd.
<br />0 rC;o[Idc@6**K
<br />II}IIIf,UCIIONIINDINCICENCT
<br />I h.rcby amnnundc. p..nlryolp.4uryihd rhm is r conslruclion lcndinS a8cn.y for rnc lsfoirEncc oflhc qor* lo! which lhh pcmil i
<br />issucd (se. lrr97. ci! c )
<br />AP&ICANIDSCI.ABA.UON
<br />I ho.lry a]Im und.r Fn,ll, of rcrjury onc oflhc fouowins dcclaElions:
<br />Dcmhiotr Pcm $Astf,sros NolifEalion Fcdcml RcSuhrio.s (Tirlc &. Pd6)
<br />-Requircd
<br />t llcr of Norificarion
<br />lcdilylhrr rhc l.d.rrl rcguhrn,n\ frgIdir! r\h.{o\ rctrnrrlrc mr r|rpli.lhl. t, rhn pruJ.cr
<br />f .cniryrhd I hr\c rc.d rhs lpplicarion md s.rc rhar rhc 0trrc infonmr t corccr I apre locomply wirh lllCily lnd Cotrnry
<br />ordimn.cs ,fld Srarc b{s Ebl in8 to builditrg conshctio.. on hcrcby
<br />rb.!c nrnr'.Md rmn r) lN,n\r{dnn pu'F'$!
<br />nrarivcs oflhn City aM Counryro enrs uIonrh.
<br />'t!/i(inr .r ,\!rDr siruluro
<br />p"*'**-"rpano,)(- {Nt{ ttD
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab i Floor
<br />Bonding / Groundinq / UFER {lhl8 Flv]n't:t *-/@
<br />Transformers I
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Solf it Rouoh
<br />Ceilings (T-Bar Rouqh)
<br />Meter Release
<br />Rou gh
<br />Service ltrleter
<br />FINAL Vlr)ltB 7-r,trtx*,"/
<br />Notes Remarks, Etc )l
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<br />ELECTHICAL-INSPECTOR RECORD
<br />*,. - oC ("rG (,oott
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