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APPROVALS DATE COMMENTS OWNI'R BUILDER DELCARATION
<br />I hcrcb, lfiiln undcr pcnalty ol lcrrury lhil ! un crcm fmrn rh. Conrrlclor' l-tctrr t w for rh. lollo*in8 EN,i (scc 70.l l 5
<br />Bu\incs lnd Protcssi{,n Co.lc): Aoy Cily or Cou.ry {hich rcauircs s pcrmit io snitu.l. slrcr ihProva d.nxrNh ur rcNtr !
<br />{dcrur., I,itrro irr issur.... ds. rcquncs rh. +rlkdr for \kh Fdn t, filc a siSncd qatm.r rh lEor sh. h liccnsc,l I[GUlnt
<br />t, rhc povniinN of rhc c(,nrractr\ I-iccokd lls (Chaprcr 9- Con mEiiS wirh Sccrn,n 7(XXl oi Divirk,n :l ofthc Au\irc$ trnd
<br />Pnrfcssi,nx Codc) or rh.r lrorsh. nrx.ihpr rhcr.fr.nrnd rhc h*is fitrrhc rll.Ccd crcnrfrion AnyvioliriotrolSsrhn?0:ll5hylny
<br />lmli.lnl ld a pcnrit suhjcrrhc q'lliconr to rciviltcn.llyormr mlc thm fivc hutrdrcddolhrs (5500).
<br />I. x o{ncr oirte pmpcnr. or dycfipbrcel wirh wascs as rhcn n,b comt nerion- willdo rhcqo&d rh. sl lm is ml
<br />inlcfttjd or offcrcd for slc (Sd.7tX4. Busirc$ ,nd Pmfcssn,ns Cdl. 'I hr Conr.dor's Licen$ tjw docs nol apply lo an osncr ol
<br />rh. pmpcny *ho tuilds nr nr{,ohs rh.Nn. dxl who dks skh $urt hi'n\.llor h.r*lfor rhmu8h hk o. hcr osncmploye€s,
<br />prolidc{ rhar such irymvcrnrs m n.l inl.ndcd., oftr.n hr !lt.li howcq.lhc huildios or irrrcwftnr i\sldwirhin.N }ta
<br />of.o,rpLion. ttE ownc. Buildfi will hrw th. bud.n or proviry tl'r! lf or sh. dil tror tuit o. in{,mvc thc pmpcrly fu thc IUrF s o,
<br />E+, * n*,. nr rt l)fi,r'.ny. ,n cxclusivcly o rucri.s wilh li.cnscd (onnacroN h con{rru.lltE rmj.cr (Sc. ?oa4. Bunndsr
<br />md P$lc$ir codc Thc contr&lol s Liccnsc Lnw docs .ot amly ro rn owncr of pmFny who builds o, imDrovcs ircreon.
<br />rtrd *ho cootrcrs tur \uchnm]c.ls{irhrConrn'.xn(sr li.cn I tuAurni rorhc Contrcroi\ Liccn\c bw).
<br />I JmcMrr UnJcr \cdFi
<br />,","481!i)
<br />Ihivc rl will nlinuin ! Ccnillclc of C.n\c b Sclf lnsurc tn *o c6Lr,n|Ensmn)n,rc pmvidcdforbyScctinrl70l)o{rhc
<br />lihor Codc. io.rhcllc orro.ccoflh€ wodr io! Fhth lh. pcmril i\ hsucd
<br />lhrlc rnd $rllfirintan, work$a ronfrisarn)n insrruncc. a\ r.qrned b!Sc.r()nl7(x).frh. hhor Cidc. iu rhc p.rli)nu,mc ol
<br />llic trork for whi.h rhh lxnhir ls is{cd M y *orkc6' .onlrn\rr i(,n nNrfutrcc .drcr aM F)lict Nnrb.r trc
<br />Puli.yNu'nbr Exptcs
<br />!+{.cdiiythd irrl[ lcrfoirnaRr ollhc work lor whichlhh [l.flnn n tsucd.l sh ll nol cnDloyatryrrnon in rny rnNr
<br />\, 6l$om suhrcd h rh.sollcrfco,nFnsrri,n hws ol Calii,nnir. r agN rhar irI \hould h.dnm subjNi hrrtu
<br />so*.rl .onpcnslrii)n nmri\n,trs ofSerion l7(X) ofrh.lrhr C.dc. ! rhrll. Lnhsirh coflplt sirh lho$ provisi.ns..
<br />WARNINC: Failurc ro surc uorkc6' comrcnsalion covcmBe is unhwful. and sholl slhj.rr an c'nplorrr ro sinnn,l FtuIin dnd
<br />civil fiDcs uI to onc hundrcd rhou\nnd dollars ($100,000). in irn)n io tlrc co( oi uompcns!rion. d(.usc\ ds pR,vidcd f.r rhc
<br />o"r", \rr(Y r u-t
<br />i.tcrc( Md inoflEy r lccs
<br />Ihcrctiy arfid unddr pcnulry.rlcrjDry rhrr I a li.ci*l u.dcr in)visi(,. or Chlpl$ 9 (..nnftNir8 wil h Sc.t iotr 7O(xD ol Division .l
<br />or rhc B!\irc$ Md Pnlt$ion\ Gdc. lxl ny liccnr n in ,ull lorce ad c,Tcrr
<br />Lcndcrr N!m:-
<br />APILIIANLDESAAtrII.IN
<br />I lut6y dl'mn undcr penalry of plrjury onc orrhc nnbwn,g dccllrarions:
<br />Dc mliln,n P.nniIr Asb.(os Noiilicrrion FcdrrrlR.Euhtio,\ l, irlc 40,l'rn6)
<br />Rqun d l.rr.rof Nrrillcr.oi
<br />I..diry rl[r rhc tdcrrl tr!trl.ri(nN rclrrdirE rsrr(os rnhvrlnrc n.r rr'!li.nhlc r. rhn nnij..r
<br />ion. md hcrchyaurhorizc reprc{nr ivcsofrhtCiryodimn.cs md Sr.ic lrws rcllli
<br />a&)vc rnridrd pn)flcnvlir in
<br />A pplicnnl or Agenl Slqnoluft:
<br />Pcrnilm mn. i prin0:
<br />'?eooov'-t ?;fr*.*
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Lighl Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm i Dam pers
<br />Communications Cable
<br />Building
<br />Bondinq / Groundino / UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />R ool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilin gs (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rough)
<br />It4eter Release
<br />Rough
<br />Service Meter
<br />FINAL s-|.7.-\e J).5p
<br />Notes, Remarks, Etc
<br />ELECTBICAL-INSPECTOR RECORD
<br />ID/SIG.
<br />Under Slab / Floor
<br />Air Conditioners
<br />,4<y
<br />I hcr.hyxl}nmunrl.' F-nxlrr,'l trrju'!otrr.frhcf{,ll,rsi"gn.clrrri,r\
<br />g)lgauclloNrENlltlljlliENcr
<br />Ihcrcbyffiinnu.rpcnaxyofFrju,ythdlhcrchronstucrirnLndinSngctrcyforlhcpolonrurcsofltc$orkror*hichrhnr.nririr
<br />i\sx.d rsc. ]m7 Civ C I
<br />II
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