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APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATTON <br />I h.rcby trfl]in utrdcr l,cnllry of pcrjury that I am cxcnpt from lhc Coituro6 Liccne tjw lor thc iolloqins rcasn (Sec.?011.5 <br />lrusincs ond Prolc$ion Codc): Any Cny or CoMry which r.qums a FJ,nii ro onnrucl. trltcr in mrc. dcmlkh or rcllln dy <br />sro.rue. pri, to irr is\uftc, al$ r.qxircs rhc atplica for such Fmn to fik a sisncd srcrc'mni rhd h. o. sh. i\ [Nns.d putru t <br />!o rhc povision\.f rh. C.nhcror's Lkrnsdt bw lchap'cr 9. Commcncins wilh Section 7000 of Division I orrhc Bu3incss md <br />Profcsions Codc) or lhol tE or sfic k cxcm lhcrcfrom ond lhc hosn for lne aucg.d cxc'nprion Atryviolalionolscclion?0ll.5bysny <br />0rpliclnr for a pcmir slhjars rhe lpplicur ro i civil p.nxxyornol mrc rhan 6vc hundrcd dollas ($500). <br />-1. <br />as owncr of lhc pnlcny, or my cnDlorrcs wirh w,g.s al rh.n $k comF.$lion. qill do lhc wo a,n {E stnh@ n frn <br />i.r.ndcJ or oficrcd lor ulc (se 7044. Busincs ond Pmicssions Codri The Conra.t,t Lkcn* ljw des nol a!/y to 3n o*ncr of <br />thc F,pcd, who builds or imrbrcslhoso. lrxl who dfts such wott hi'nsclfor h. cllorrhmu8hhhorh.rorncmPloyccs. <br />providcd rhrr such inrprclcmnls m mn hrcdcd .r ofli,.d ror slc. Il tb*cw, <br />'trc <br />huildine or iq,mtmnl ir sU *irhin .nc ,cu <br />ofcoqrLriotr rt Osncr Builds will hnh rh. hrd.n ol pmting thal hc or shc dn rcl buiH or i'qrew $c tqEry foi Lhc tn Fe or <br />-1, <br />osow.cr oflhc nropcny. rmcxclusivelyconrE linx qnh li.cnscd contukrs lo.onencl ihc poj€cl (S( 7(144. Burinc\r <br />and Prdrsbn Codc: Thc Co.t.tor's Licc.sc Lnw docs.or applyro inowncr of proli.nr eho builds or inprovcs ih.r.on. <br />and wlD onhds lor such poirIs wirtaConrE ro(s) liccnsd lu^uMr ro rh. Conea.rols Liccn€ LIw) <br />I 0ncrcnrpt undcr Scclion ll & l'C l(tr rhn rc nn' <br />ulr86E8S:lOlIrDNS rlQN <br />DECIdEAIIQ! <br />I hcrcby Jlfirm utucr pcnrlryolDcljury onc oirnc tallowinE dc.lararn n!: <br />-l <br />htrvc and will minrsin s Cenificrrc of Consenr lo sclalnslo for worr6 onp.nstrn. as pmvidcd for by Scclion 3?00 of lhc <br />tibor codc, for $c F lormrcc ol rhc wort for whicn rhc pcirnir is iisled <br />I hrvc.id willnuinrdin workcrl .ompcnsliion i.sMtrcc. rs rcquncdbrSftridnlT00.arhcbbotC.dc,forlhcpcrfonnorccol <br />rlr wo.k ror which lhis pcrn l is ksucn. MyworkEC ompcnsation inlu.ancccuicr ar'd roli.y numb.r t.: <br />j4l ccn'ry rha! in rhc ncrrorNmc orrhc wurk fur *h'chrhis p.rmn n ksucd.l shlll nol c$ployany p€rsn in lny turcr.-s xs ro h.sm subl..t ro thc wo*cN (.mpctreron laws otcllilomia. and lse lhar ifl should b..oft sbj..r ro tlr <br />workcn.ompcneriontovtionsolScclion3?00oflncLlhorCod..lshall,fonhwnh.omPlywnhfio$pmvilio.s.. <br />b onc hundicd thousud doll.rs lSl0O-000)- in oddirion lo lhc co$ ot cornpcnsariob, damgcl as porid.d for thc <br />Sc.rnr .1076 of L[. Labn Codc. i crci dlxormy s <br />\^,|V??/21 \e <br />IECI,ASAIIQX <br />I hcrb, sLtrm undq lcnlhy oi p€rFry lhol I afl liensd under lrovisi.n 6r Chapr.r 9 (orlmrcnrg wilh Salion ?000) ol Division 3 <br />of <br />'hc <br />ausimss and Pmfcssions Codc, {d my liccnsc t in frrll fole ud .fldt <br />I t04ll3I <br />€lectrrL#\ =\.,,..",.., Flati <br />CON5IAIgU()I{IIIDINGAGINqI <br />I hcrby atfifln unds Fnalrrol pcrjury rhur rh,r n a e.sttucrion lchding rg.ncy ror <br />'h. <br />p.rloMcc ollhc wo.k lor whichlhis pemit is <br />issucd lsc-. 1097, Civ. C.) <br />APPI I(]ANT DE(1 AI{A'floN <br />llmhyafimund.r p.nrlry otpcrjrry onc otrh. f(rkrqirg dc.lrflriotrs: <br />lxnElirion PcirnirlAst s.s Norilicarion Fedcral ReEularions ('rirh 40. Pd6) <br />-RcquncJ <br />krrcr of Norifi.didn <br />!..diry rhar Ilf, fcd.nl E8llalions Eg&din8 rstEslos rcnbvolarc not lppliccble ro this pre,..r. <br />rlll ccn'ry rhJr I hrrc rcd rhn apnlndion r'd {,rc rhr dc.bovc inlbrnElion k cotrEt.I acrt,&dply*irh rll Cirya.d Counrt-udoJ.lcr J shrc hwr rc|0fio3 ro burldrn8 connrucuon. md hcrcbyuurhorizc lcprcrortrrivcs ofrhk CnyaM Coutrlyto cntcr upon th. <br />uhorc f,trrnnLi[opc y Inr irspc.rdrlllrpo€s <br />\pDlicsr or {ecnr Sigmrum: <br />\ Pemriler n6nr(rnnl):,urtrn K-let* <br />X"? ? , <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Salety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Transformers <br />Torqueino <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilings (Hard & Soffit Rough <br />Ceilings (T-Bar Rouoh) <br />Rough <br />Service It/eter <br />FINAL 74-zr /.ztst v^eza>vZA <br />Notes, Remarks, Etc <br />\ <br />ELECTRICAL.INSPECTOR RECORD <br />Meter Release <br />Cuk! <br />Irndc'\ AJ'lJr\. <br />I <br />:[------T------ <br />II <br />ti <br />I