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APPROVALS DATE ID/SIG.COMMENTS OWNER BTJILDFJR DgLCARATIoN
<br />I hcrchy rffirm u cr pcmltyof rcrjury rhor I mcxrmp' rmm lhc conlncroa Llccnsc ll* ror rh. forlowing rc$otr (5(.1):11.5,
<br />Blrin$s d Pronsion Codc)r Any Cily or County phich mquics r Frmn to .onnrud. 0llcr. improvc. dcmlnh or Rran en)
<br />{ocr!rc. pmr ro irs hslancc, lho rcquircs rhc appltotrt lor such lEnnir lo fik . si8ncd st0lcmnl thnl hc o! $c is lienscn pur ffr .
<br />lo lhc fmvisions ol $c Conractols Liccn\cd bw (Chnprcr 9. Co'nmcncing wirh S..rn,n 7fiX, ot Djvision I ofrhc Busincss rnd
<br />Polcsrions Cod.) or rhal hcorshc ie crcnrpt thcrctonMd rhc h$h rar !h. rll.C.d cxcnrpri(,n Any violalbnofSNlionT0ll.5 by!n,
<br />,mli.a.t nrurcmil subFcrsrh. apnlicrnllo rcivilpctrllryornor 'ree lhln fiv. hundrcddolhx (3500)
<br />-l-
<br />0s owncr ol r hc pmpcny, or my cnldo)rcs wnh wag.r I Ihcn s,h comFilr i(d. will do rh. wdk drl tll itu is nol
<br />imcnLd oroffcrcd for slc (Scc 70{4. Btr\incs lnd Piol'c$ions Codcr Thc Conrrrclols l-iccnsc ljw docs tror lpplylo !. owncr or
<br />rhc,mp.ny who hoilds or iqmilslllBn.ond who &f,s uh fr),* hnnsclfor hcrslfor rhmugh his or hq.*n cmploy.cs,
<br />pr.vidcd r har s!.h intmv.mnrr m mr L cM.d or ofi.rd for qL lf. tk)s\u. rh. t iuinE .i nr{lmwm.r is sU rnhjn oN Fr
<br />.f.\[plcrioo. rtE Osncr Blildcr will h!!c lhc lorden of ,mvinB lhrl hc or shc dn ml hild or nntmre rhc i'otoly lor lhc plqns of
<br />l..wnerolrh.pmpcny,ameiclusilel,conrracrire*irhlicetrsdconhcrosroconarudrh.pmJ.cr(SN704.r,Bu\inc\\
<br />ul h)rassam Codc Ihc Conrachl s Liccnsc tj$ dds nor dmly r. an owrcr or rrot'.fly wk) builds or inDrovcs thercor.and who .ontacs for su.h p(&crs wirh 3 conrracnn(, liccnsd pursuunr ro I hc G,nr,actoi s l-iccnsc Li*)
<br />Lndxc.'rt und.. Sc.rt,n
<br />-.U
<br />& PC. rb!lhis rurson
<br />larf,lBlrl)uftiNsallaN
<br />DIICIAXAIION
<br />I hcrcbt amrm utrdcr pcn3lryolF,juryom ollhe tollouins d$llnriotrr
<br />Lnhtr ('( c. r(trrhcpcrtonrtrrc olrhc qo for $hich1,r lcrnln is i\\ucJ
<br />_l havc.nd will minhin{orkcs c.nDcnsllionin*udkc.L\,.qui6dbys(rtunST0oolth.tjborcodc,lorlhepdlorNmcof
<br />Itc hrt lo, vhicn fih r..mil isns.d. Mywolkcis m.rpcns0rion nrurmcc c.rtr ud policy numbcr ec:
<br />-T (,.c KT,.(gcL-an7e
<br />K:
<br />a
<br />0 Z0(o o ll-l-tff
<br />I ccniryrh,r in rh. pcrr.rromeorthc work ror rhichrhG pcflnil n issurd,l shrll or cnuloy bn, pcrn,n ii siy mMicr
<br />s a\ro bcco.r subj.d to rhc wor*c6 smn ns iotr hwr .f Cxli&,n,ir, dnd rgru.rh ifl shouu b.c.m suhjet rolhc
<br />woltss compcnsariotr,rovisio.sotSccrionl70l)olrh.tjtnrCodc,Ish r. rdhwith comply w irh rhor pmvisions .
<br />WARNING rtibrc b *curc workcs conlEnsdion covodg. ir unlrwful. rnd shrll subiccl M cnrllolcr lo oiminal Fnrlrics and
<br />civil fincs up k, om hundRi lhousand dollm ($loo,ulo), in ddirion ro thc .o{ ol conD.$rlion. d! Lr8cs as rroridcd r'or rhc
<br />!.rr,, \rl',rrtr(1.,r\1(,Jc nJ ...r1.. r -! l!.
<br />Y,,,,5-1?- ty,,,,,,,.,,, h/,ll;o--,
<br />DOCI Af,,ATlTN
<br />I hcrcby affirm u6d.r pcnalry of p.rjury thal t,m li&nrd undcr pDvGion.rChero 9(comftmin8 wnh Smlion ?000) olDivGion l
<br />da lhc Btsitussun.l Profcsions Codc. ed nyliccn$ n in tull forcc url cittcr
<br />a*"
<br />\Du'c
<br />C.,D 7fftv$
<br />L->o-tt .q(LCLi.hi,-
<br />J:ANSIBIJCIIOITIENDINCIGENIJ
<br />I hcEl,y rmrn ldcr pcnaltyofllcrjlryltar thcrc t a conslru€lior hndin8 o8eftr aor lhc rcrfomncc o{lhc wDrk lor wnichrhn pcmi n
<br />nsucd lse.3097, Civ. c.)
<br />6ITIIIA!I.DEI;LI!AII!}!
<br />I ttc4 a6'm undcr lEnahy ol pcrjury om of r followi.g del,.rl irri
<br />Dimlirion P.rmirs.AstEsros Norific.ri,n FedeBl Rc8ulirions (Tirlc 40. Pad6)
<br />-Rcqlicd
<br />ldlqof fiotific hn
<br />I ccnifyrhd rh.ladcBlrcgulari(r\ rc8rnling ashc{os rcnmvtrlrr. nor rnplicrhlc brhis prcFcr
<br />lc.nllyt r lhiE rcM thi\ lJ)plicdionrxl{ .rhrlrhc lmvc Ltrn)rn[ri( ](..rccr laerer).ijtrtly\riihillCilyrtdCounry
<br />+,.*:I":;;:::"'"Wq'^ #4,,"," f-ta -t 6
<br />\""**.*.",,n,,,Lllt I I t *^ L. ]ft./a-
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceili ngs (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />Rough lr.\
<br />ZService [Veter /rl /- , /.<2 )x )/t )
<br />FINAL )7 "/ "?/ l0 ry5 7v
<br />Remarks , Etc.
<br />ELECTRICAL.INSPECTOR RECORD
<br />Communications Cable
<br />lvleter Release
<br />Notes,
<br />t rln \ AJd.r'
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