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APPROVALS DATE ID/SIG.
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Liaht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safetv /Low Voltaae
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildina
<br />Under Slab / Floor
<br />Bondina / Groundina / UFER
<br />Transformers
<br />Toraueina
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipm e nt
<br />Factorv Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Soffit Rouah
<br />Ceilinas (T-Bar Rouah)
<br />Meter Re lease
<br />Rouah
<br />S erv ice M et er
<br />FINAL
<br />Notes, Remarks, Etc. V
<br />ELECTRICAL-INSPECTOR RECORD
<br />COMMENTS OWN EH UU ll.l>EI{ l>EL C AHA TION
<br />I he rch y affirm 11mlcr pe nalt y o f perjury 1h,11 I :un e'<\Clll]l l frnm the Gmtrai:111r,;· Lit·Cn"-c I.aw fur ilw fnll l1\v i11g n.•:1"1111 i Sl'i.:.70.11.5
<br />13usine!-S am! Pn\fe,;siun Cndc): Any City nr C'nu111y whic h req uires a pe rmit tu c1111,;1ru1.:1. ;1ltcr. impnm:. 1k-i n1d i,;h or re-pa ir :my
<br />:,;tnll'turc, prio r toils issu:mct:', alsn requ ires l hc a ppl il.:a11t for sui:h pt·r111i11 11 fik :1 ,;iJ!11ctl 'i late111t·111 1ha1 lie 11r ,;h,_• i, !kcn,,.·d pursuant
<br />lo till' prm•h•io 11'-or lhc C1111t r:u:tor",,; Lkcn~cll L:1w lChaptCI' 9. C11111mc111:i ng w ith Si.:i.:t i1111 70IMI nf D iv i,im1 .1 o f lhc B11,;i11c,;,; a nd
<br />l'rnfl's,;ion, Cntlcj or th;1t he nr ,;he j-. exempt thcn,:frmn a ml !ht· h.1,;i-. f11r the ;1ll q!t'd t·\t:111p1i11n. Any \'i11l:1tin11 of Sc:c:t inn ill,1 l ,) hy a ny
<br />app!h:ant f111· a pcl'mit su hjec:\,; the applic;u1t 1t1 a dvil penalty uf not mnri: 1h:111 five humlrl.'d llollar,; t\:'\Oll f.
<br />_I. a,; nwner oflhc pr'o pcrty. u r my cmp lnyecs with W:IJ!t'<; :1-: tht:i r -.11k comrcn,al inn. will Jn !he \\'111t and thl! ,;1n11..·111rc i~ 111 11
<br />intt•tuleJ ur u ffen·d for salt-(Scl·.70-l4. Busint•<:,; :md l'rures-:inn-: Code: The Cm1tr:tl'Wr'.-. Lil'l'IN : I .:1w d11t'<; 11111 :1pply 111 :111 11\\'Ut~r nf
<br />1hc prnrcrty whn huiltl'-o r im prnvc" 1hcrenn. :11ul who doc'-<:uch wnrk hi nl',elf or licr<:elf or chrough hi, 11r he r ,,,,·11 c 111 p ~1ycc-:.
<br />prnvi,kd that sm:h i1np 1·nve1111:11(s are nnt inlcrnled nr ofll'rt'tl li ,r <::1le. If. h1111·e1w.1he hi1ihli ng 111' i111prun::m.:11t i-. ,;old within o ne )l'.ir
<br />uf c:ompk:-t ion. the Owner Bulkier ,viii han: lhc hurdc111 ,r pn1\'i11g th:i t he 11rshc tl id 11111 huild u r i111p101·c.• tht: pmpc.•n y r1 1r Ilk.' pl lll '-''l' ,,r
<br />-:ale).
<br />_l. a._ nwn cr of !ht• Pnllll'l'ly. ;1111 t'Xt.:111<:i\'e ly c11nl r:1cti111! wi th lit-c-n~ed c11ntrnt.:t11 n:: 111 1.."11 11,lnit·t t ill' p1,1,it'l'l lScc.·. 70.1-1. Rlhilll'"-
<br />antl J>rnfo,-,-ii.111 C ndc : The C1111t r:1~·1nr'" Liccn-.c l.:iw dnl'S 11111 app ly to a n nw ncr n f prnpc1 I)' whn hu ihl-. or im11n1rc-: lht'lt'•111.
<br />nnd who contrnt.:I<: for ,;11d1 pr11jcc1-. wi th :i Cn 111rac1L11(<:) licl'n>:t.:d pur<:11:1 111 Ill 1hc Cn111r:11.."t11r',;; LicCll"-C l.:1w1.
<br />_I a111 e.-:empl umlcr St.:t·tinn, ________ . B. & P.C. fnr tl1i~ n:a -.1111.
<br />IJ:.1 l c ; _________ O"lll'f '
<br />W<JHK EllS' <.Ut\ll'ENSA'l'U)N
<br />UECLAlt,\'r l«l N
<br />I he rd1y artir111 u ntlcr pcn:LII )' 11f pt.:rj ury one nf the fullnwi111! dedar:ui,111,;:
<br />_! ha\'c ,11Kl will mai11 t ai11 a Ccni!katc 11rCon-.cn1 111 Sdf-111-.urt· fL1r \\'mh·1~· curnpc11"a1 i1rn , a, p1mi1ktl f11 r h y ,c;;ct·1i1111 .noo 11f 1he
<br />L;1h11r Cude, 11,r 1he pe rfi1rn1:1m:c nf thl' m1rk fur whid1 thc pe rmit j,-i~"uctl.
<br />_1 ha,·t' aml wil l m:1intain winke r-.· co111 pr11~;u i11n iu .. urancc. a~ rc11Lti rcd hy Sl't.:!inn J 700 1it'thl" l.:ihor l·mk. !i 1r 1he pi.!1·fu1111:111l'l• 11f
<br />thl' wu rk flll' whid1 th i-. permit i-. i .. -.uell. M y worker._· t.:11111pl'n'-•ll i1111 imu ranct: carricr ;md polit.:y m1 1nher a1c·
<br />C:1rricr:: __________________________ _
<br />P11licy Numh<.'r:. ____________________ Exp ire-.: _________ _
<br />_I l'erl ify thal i111hc pcrf111·1rn1m·l" ofthl" work f11r whic h thi -: 1,-:nni1 j,; j,;-.ul't1. I sl1:1 ll n111 e1npl11y a11y pcr~11n in an)' 111a111wr
<br />!-ill a~ 111 hecmnc s11hjer.:1 tn the workl't·s· r.:111npe11<:attl1n law~ 11f C:al il'nrni:i. a nd :1gn!c 1ha1 if I ,h1111ld h,,•..:1111ll.' '-llli,jl·l·I 111 !ht·
<br />wmkcr._' COtnl'ICfl '-:ll inn 1mwi~inn<: ofSt!i.:tion .HOii nrthc L:,ho r Cw lt!. l <:ha ll. ti1rt hw ith c11111ply w ith th11-.t"" prn\'!,;in n~ ..
<br />WAltNIN(;: F:iilme In 1;ecure \\'n rkcr-." 1.:nmpcnc;:1tion coverage i<: unlawful, and <:hall ~11bjeL'I :Hi e1111,lnycr tn nim in:111w11:1l1 it''-rmJ
<br />rivil fine,; up In nne humln:d thou~antl 1lnll:1r<: (. .r'IMU }OI>). i1 · hliti1rn ln the cost n f c11111pt.'n,;:11 inrL da1n:1gc~ :1<: prn\'idt·d flll' the
<br />Si.:ct i11n J(l.76 nfthc .i1hur~'uc.lc, i tcrC"-1 ;'I d :1111, ;)' -
<br />U:ok: ~ /,_, / 2-~ ~'7_ Ap ·:o ut:
<br />L, / 7--.EN~ RAf " m
<br />1 --.. ECLffiATION
<br />1 111.:rchy aflirin undcr perml1y n r pt·rjury 111.11 I m11 llcl·owtl 11111\cr pn)vhi11n ,,rch,1pll·1· 11 tt·1111 1111enci11i; wi1l1 Sn:ti,111 7lltHl) ,,flJi\·i ,~,n J
<br />of the Bu-:inc"" nnc.1 Prnfe-.sinn" Crnle . ,mu 1ny ti ct·nst' is iu full fn rcc :rnd effect.
<br />L icen<:c Class: .,, i I · ......... , Numher: --::::::--------------
<br />Uat< ______ ~--17~, c n ,.:£ ~) -/-/--~
<br />/ JNS 'l 'l!l l':'1'1 ·£.:Nm Nt:A<:ENC\' V f
<br />~ .hcrchy a ffirm 11mle!. pc1~a ll)' nf perju ry th · tht•rc ¼·1111-:1rul'tinn k-mli ng agency fu r the pcrfm1nance nf tile wn nr ·hid11hi~ permit is
<br />1s~ued (Sec. JO~?. c,, .. c.i. -----Lemler·~ Name: ________________________ _
<br />Leuder·s 1\ddn·~s: ________________________ _
<br />Al'l'I.ICANT UEC LAIUTION
<br />I herchy ;1llin11 u11 dcr pe nalty nf perjury 1,nc of tht! foll,1wi11g det·larat ion":
<br />l)c1no liti1111 l'e rmit~•/\shestos Nol lfieat inn Fcdcr·al Rcg111:Jtio11 ~ (Til le 411 , Pr1rt fi)
<br />_lkqu ircd Lcllcruf NutifN.::alion
<br />f
<br />_I 't'rl ify ml t he th lcnLl rcgu l.nk,n" rcgartling a-.hcsms rc1111wal arc not :1pp lkahk lo lhi~ pmjc~:l.
<br />_1 cer 'fy hal I ha\·l' rc:1d lhis a pplil-aliott ;11KJ ,;;ta lc th:11 the a bun-i11 f11nn:11io n is t·nrrcl·t. I :l!_!l'l'l' 1n n1111p!)' wi1J1 ;111 C i1y :111d C111rn1y
<br />nrdinanl."C . ·1r1d St:itc Laws rcbting 111 building con~tru1.:t i11 11, and hereby authmizc represc111:11 in:'i nr thi,; Cit y and Coutll}' 111 e 111c r upon the
<br />aho\'e 11 1111 1cd pn,pct1y fur i11spet.:tk111 purposes.
<br />il1>11li<a11t nr A~rnt 7 n:ot urc: -rv/ l/~ 0 ,/ ll:11,•:~0?--
<br />l 'r1·111itl½1111c ~11 1: / ~ ~.// ~./7 ___ .,,,,
<br />...__ l
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