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APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soflit Rouqh
<br />Ceilings (T-Bar Rouqh)
<br />lVleter Release
<br />Rouqh
<br />Service I\/eter A
<br />FINAL \)thaltJ ^,HultNotes, Remarks, Etc.,l--11 tr "- -:J::7
<br />OWNER BU!LDER DEI-CARATtON
<br />I hcrchy oifirm under rEnahy.f pcrjury rhat I n ex.ntr rrom (hc Co rador'LiNnse liw tor rhc rolloNin8 rc.sn lscc 7O3l5
<br />Busirlcss rd Prt,r.scn G)dc) Any City or Counly which rcquncs a pchrir ro .on$fl.t. 0lir. inl[trovc. dcnnish or rcI)an ,ny
<br />{tu.ruo. pri.rro ns issurncc. also rcquiresthc lpplicMl lbr such rc'nir t, filc, sign.d sl.lcnrctrt lh.r hcorshe is lic..scd pu udnr
<br />b rh. prcvhion\ oftlr C.nra.rols Lic.nscd tiw (Ch0/cr 9. ComDcncing with S..rnrn 70d) uf Dilkion 3 ot rh. Buri'ts rnd
<br />Pmlcsions Codc) or thil hcorshc iscreqrr rhercfrofilnd rhc bNh lnrrh. dlc8cdcrenDlion Anylidario.ofScdionTllSl.5byuny
<br />applicanrforapcrnislhjccarhcJlpli.nnrlor.ivillrnhyornormorcthMr'ivchrndrcddollatr($500).
<br />!.xso*rcrorrhcDopcny-ormycnrploycdswilhwn8csr\rhcnk,h.olp.rsdion.willdorheworkandrh.nru.rmnmr
<br />inrcndcn oro0ercd lor salc (Se.7014, Busirrs a.d Profcssions C.dc l hc G)ilrlcrois l,iccnt L2w doN trol .pply lo u owncr o{
<br />rhc tml.ny wh. huilds or nn orcs lhcB)r. and who docs such so]t hiDselr or h$slr o. lh ou8h hh or hq o*n .mlk,y.cs.
<br />pmvidcdrnar such inrprokftn* c nor iricrxLd oiDrcntrl for sdlc.ll hwcvcr. lhc hU iltiry .r imi,otmfi hsldwirhinonc )tr
<br />ofomptb,. ttE Owncr Builds will hrr rhc ltrdcn or pmling rhd rt or shc dt tror huild o! impow lhe pDFiy for ll[ PUIIN ol
<br />-1,
<br />$oqrNrolthc flopcny. d.xclusivcly.oita.rirg wirh iiccnscd coffadoN ro consrru.r rtc pmjc.r (SL\. 7044- 8u5ir'css
<br />Md A.fcssi.n Codd: Thc Contrdofs Liccnsc Lnw docs n.l0prly ro an o(ncr olnopcny who builds or nnptr,tcs rh.t.n.
<br />rtrd qho o mcls for such lm]cck sirh r Contacrrl\) liccn\cd rur\ld ro rhc Co rcl(r'r l -iccn* Iiw )
<br />I Jn'crctrrDr undcr SNIrn . B & PC n1 rhi. rcJ..n
<br />UATtrESS-I;UIIIENSAIION
<br />DES'NAIIA!
<br />I hcrcbyrtlimundcrncnilry.In.rjury.n .f rhclalbwnrgdc.lrraliotrs
<br />I hrv. flnlvill mrinhin !CcnificorcoiConEntro Sclllnsu.e for tr!&c6 .unrrnsalion..s pmlidcd ftn hy S.crion l?00 ofrhc
<br />uhtr Co&. ror rhc p.rroflnaRc ofrhc sork for whlch ltc pcrmil h tsucd.
<br />, ha\r dtrd vill nrrirr{ir sorkcs compctr
<br />rhc sork ror *hi.[ rhh |Ennir h hn'cd My
<br />sarion insuranc€. 's reqoncd bySc.liotr l?0Oofthc LoborCodd, nJr rhc lrcrlomrtrcc oi
<br />workcrs compcnssri.n i'ruran.. caricr md policy nunbcr ue:
<br />lvgr-t{ kN "&U ,F rW w6r
<br />iogao
<br />-l
<br />.cniiy rhar i| lhc pcraormrnce.frhc work fu whih rhis F'nir C nsuca- I shall nor cnDk,y any |.6on ir.try nmnncr
<br />$ rs b b.co r. suUc.r kr rhc workcn co,nFnsdion l.w$fcllitnnia, rtul iltc rhar if l shotrld hccom subjccr io rh.
<br />workcA.olPcns ionpovisiotrsofSdioD3?u)oirheLrhorC.Jc.lrhtrlr.tun[wirhcomtlywithrlntPn!tn,n\
<br />WAIININ(;: liilurc 1o ssurc workcr( conll)cnsdioo cortug. ir uninwful. md shrli subJ..l m cn,pk,ycr h Lri'n$.lN* ic\ un
<br />.ivil fircs np lo orc hn.drcd lhouslnd dollar\ ($lo0,o(lo). in addi ro thc cost ol compensqrion. da [gcs as prorided r'or rhc
<br />s..r'nn 1r,76 ofrh.l ahor Codc rrercrr
<br />V,.," . f-r[,*
<br />DECIAEAIIO!
<br />I hcrchy nfiit! undo pcmlryofpcrjury lnrl I an liansd under lrovision orCh,I.r 9 (omnrcrcins with Secrion 7(n0) oioivtion 3
<br />oi lhc BusnEss ond ttolissionr Cod., and my lhcnsc h in till lbra dd cl'isl
<br />0ro* I j<Ln-(e:l
<br />5 ?-\{l Q ..,,..","., lvlt tcltJL aaso,t-L Ca4t1,1! {
<br />T]ONSTRI](]TIoN I-ENDIN(; AGINCY
<br />IhcrchyrffinnunJ..pcrlr!olt)crjuryrhdIhcr.isrcon{rudbnb i'rgxScncy nrrhc PcnonMtrcc ollhcsork i{r{hi.hrhi\ Ifnnit is
<br />tsucd (scc 1097, Civ. C.)
<br />titrd.asNa.r:-
<br />AITLICANLDESAAAT9N
<br />I lBrby llltmundcr pcnalry ofpcrury orc ollhc i.ll.win! dcclarariors:
<br />Dc'nolnion P.irnils-Asbc{osNorificrionfcdelal RegnE i{rns(Tirld40.Pd16)
<br />Rcquncd L.ncr oi Norifi coliotr
<br />l.crilydid lhc icddrlrcsuhlnnx r.Erdina rsbeio\ ru'noul rrc or Uflic$lc kr Ihis F)jccr
<br />lc.dilirharlhrvcrcrtlrhisrtfli..rionrtrd{dlclhdthcahi!crtrhnMi,)niscorccrIa!a.!r,.orl,yqirhallCir}xtrd(,ndy
<br />rucrio.. Dd h$cby iulhorizc rcpr.scnr ivc\ oflhsC
<br />ihov. nrori,,tr.d Dn,tIrt lin N /'7----It41x+k
<br />' P€mritee Dnre (prinl){rL t"€z-
<br />.p I L
<br />ELECTRICAL.INSPECTOR RECORD
<br />h.4 t?1,.w-- - --f------
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