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APPROVALS DATE ID/SIG.COMMENTS OWNFJR BUII,DER DELCARATION
<br />I hcrchy allirn undcr pcndlry or Frjury tl[t I m cxcnrfl lmnr lhc C.ffncloN Liccnsc Llw for lhc rolkr{in8 icasn (s...7011.5
<br />Busnr$ ind Prcrcsion Codc): Atry Cny or Counry whkh rcquncs ! Irmir ro onsrtucr. all(- iflrov.. d.mlkh r mNn My
<br />iructurc, rlhrlo ils hsumcc. aho rcquncslhc appliclnr for such Frnir t' ljle a signcd ndemc rhtr lror shc ir licctrscd PuFunnl
<br />ro rhe pn,vi.n,n\ of rh. Conrn.k s Lienscd hR (Ch!pl6 9. ComNrcing silh Scclion 7(XX) of Di!ti,'n I ot rhc Bxsin.ss and
<br />PmicsidNCod.) orlh.t hcorshc is crcnpr rhcrclromlnd Ihc hrst lff rht lcscd.xrnrrion Anyviol0rio.oIScclionT0:ll5hyany
<br />spplicanr|orsr.rn,irsrbic.hrhcanpli.rnrror.ivilpcuhyorno!'norcrhlnfivchundrc.ldollm(35mr
<br />L as o*mr ofrhc ompcny. o! myemploFcs sirh !_.Ses !\ rhcn {'b cory)cnsdion. Nilldo rlx *ork ll rh. {nrluE i\ n'l
<br />inrcndcd o. olltrcd for elc (Sa 7014- Dusines and Prdi$nrn\ Codc Thc contrt s t,icctrs Lnw docs nor onlly h m ow.cr or
<br />ih. ptuB.ny stF buikls or inqn ovc\ rtEDn. '!d wh. dE\ su.h *.rt hnnscllor hcr*lfor rhnulh hi. or hcr.wn cnlploycc\,
<br />fiovidcd rhar such i'rl|Jmvcfttrh m mr inrcnddl or orcr{ ftr eb. ll howcrr rh: hikling or i'r\To\t t n $U *ihnr onc )tr.
<br />ol complcrion- rhc Owm! BuiUcr *ill hak rhc brnlcn ot pa,ving rhd hc or \h. dd n r build or nryolc thc lmpdy tu lhc Ntr\c .a
<br />L aso*tur ofrhc Fn,pcnr. r,hcx.lusivclycoff{tnr8 Nirh l,.cnscd conraclois lo conslrucr lh. pmjccr {SLt 7o1tl, Busirtc$
<br />a hDlis\ionCo.lc: l hc Conrrsckr's l,ic.nsc l-aw dncs nor f,pply rd unowncr orprorcny who huilds or inrprovc\ rhcrcon,
<br />.nd *ho conra.rs inr su.h,,rorck wirh ! (onrracto(I Iiccnscd rucuonr ro rhc Contxcrois Lk.n\c hu).
<br />-l
<br />ascxcmpl undcr Selio
<br />lI9468&tlArltElllArrl!
<br />DECLAAA.IIO!
<br />IhcEhyrinrund.rpcnrlryorr.rjuryoncof rhrft,llovin8d(l arn,.\:
<br />zt hrlc d*l willminrain aCcdili.0lc olConscnt lo Self.lnsurc tu wortc c-mnenern,n.,s pmvidcd turbySslion l70O.Irhc
<br />r Glle. fq rh! prrfoffic of rhu wr* for which rh. p.flnir i\ hsucd.
<br />I htrv. rnd willnrinrrin workcrs c.nDcnsrrion nru.rncc. rs rcquirca hy S(r i('n ]700 .f rh. I2h, (]idc, for rhc Pcrtormrmc of
<br />rhc work ror whthlhis pcrn r is issucd Myworkcs co,npcnsrriotr insuamc $tricr r policynumb.r:trc
<br />.\-L /l
<br />"^*r^-,*, - 1 lf 81*,/ ..nn*,
<br />I ccnify rhrr i. rhr Frhrnlin.c ofrhc *ork lol which rhi\ Nnnir n i$ucd. I \h!11 nor enrplo, an, p.r$n in rny nrnmr
<br />v, N to b.com subl..l h
<br />'hc
<br />w.rkc6 comnctrsotior hws .i Crlilon,ir. rnd rgrc. rhll irl slNUld b..om subr.il lo llr
<br />$ortcn con{,cnsriionpmvi\ionsoiSccrion:lTlnolrhc ljk, Conc.l shlll- ronhsnh. nrly q rh rln,t pothion!
<br />$l\RNINC: Friluru n, {cnrr qorkc^ .o txtr{d([i( ufh$lul. md \h!ll \uhi.r an cn' o)[r ki m ritul Fnrkics ll]
<br />dddni.tr h rhc co( or con,lxn\rrion. drn gcs rs |roviJcn n)r rlrc.ivil ,inc\ !p ii oic hundrcd rhousr dot
<br />'*,-f/9ap5 tI!.!NSt iJ_ta!r&ull).u
<br />t2crl, .BllroN
<br />I lErcl,yailrmundcr|EnnllyorFrjuryrhrr I li.cn$dnndrr tdnn)norChrprs 9(comnrncing sirh Sc.rtin7(Xnr oll)n1(rn l
<br />rhc BusirEs.nd Poli$ionsCndc. rnd nry lkcnsc i\ in fulliorcc mdcn_.r
<br />//- B oz(,/e4_4"!r,4=^7,-'
<br />IlErchy.fltnrundcrFtrrltyol'pcrjuD- rh3rrhcrck!connrudionl.ndinga8cn.yf(trthuP.!loiinrmc.llhcworklirahi.hrhi\If,nnni{
<br />AEUCANLDIiCIAAAIIO!
<br />I funitry adlm xnd.r ,.nall, olp..jury onc ollhc fouowitrB dElmlions:
<br />DcnElirion Prnrirs Asbcsror Norificdion Fcd.rtrl R.Sxlario.\ (TirL lu). Pon6)
<br />Rcqun.d kn.r of Norificarioir
<br />lccniiyrhrl lhc lcdcrrlrcsuhlionsrsrdinE o+c{o\r.mral,rc nor rp i.abh b rht Pn,.rcl
<br />l.r'r lr rlrr lhxr,.rd thtr rt i.orion d sarc lhar lhc itnrc irfoinrar ion h comr I nsc ro c.mlly sirh alr City and Counr y
<br />buihnrS con(rucrion. ,fil hc rcby dut tnrizc rcprc{.rlliees ofrhis Ciryand Counly ro cnlcr upon rhc
<br />mv. nEnrbncd DoF-ny tu i,r
<br />(eaz-c.€ 9a4rz,,^Zg"2z
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monumenl)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondinq i Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)//y'r//* e '/n772-,/tL_
<br />Ceilinqs (Hard & Solfit Rouqh )/5/,*''->rlrr2'2,4)-
<br />Ceilinqs (T-Bar Rouoh)
<br />Meter Release
<br />Rouqh //hlu'z ?y*zrl -k2--
<br />Service lvleter
<br />FINAL Jthhk ?zwzn la-
<br />Notes, Remarks, Etc
<br />ELECTRICAL-INSPECTOR RECORD
<br />i{\u.d rscc l0i)7. C1v C )
<br />trr,t'.\.,rtr
<br />kndca( Addr.s(
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