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APPROVALS DATE ID/SIG.COMMENTS OWNEI BUILDER DELC RATION
<br />I hcrcby afirn n.dd ,.nixy of p.rjury rh,r I .n cn.rU from rhc Co.r,cl.N Liccnsc L!{ for rhc follosins .caen ($c 7o:ll 5
<br />Businc$ arn Pmrcsiotr Codc) Any Ciry or Counry wnich icquncs a ,'sn l lo ons!tucl- olrcr inpot- dcnarh! r rpJn uny
<br />srturr rc, plitr t, ik nsurcc. alv, eqntcsrhc ippli. r for such ponir ro Ulc asig..d natmhr rhd tEorshc Ls liccnscd puNmr
<br />h rhc pmvisions olrh. Cotrrracrols Licctr\cd tie (Ch,rrcr 9. AnnnEncins *irh Sccrioi 7(xxr dr Divhnrn:r orrh. Busin.s rnd
<br />Pmtas\ions Codc) or lhrr hror (hc hcrcmt r lhcnfi. Mdrhcbashf.rrhcalLlcdcx.mprion. AnyviohlionoiScclion?Oll.5hy.ny
<br />aptlica for0l).mil subjcchlh. opplicanl lo!civilrcMhyofnol nnrclh.n nvc hunnrcd dollars ($50o)
<br />l. !s owi.rofrh. proFny, oi ny.nphtr.\ silh er!.s ar ihcn e,h .or{f,nsrlron. willdo rtr etrk {d rhc slnrlurc h mr
<br />i cndcd or oficrcd lor solc 1s(.7o4,1. Busincss lnd l'rofc$ions Coler'Ile Conracror'\ I.i.cn* trw do.\ nor rlrly o an o*.c, or
<br />rh.pmFdy whubdldrorir lm,v.s rh.r6n. ond who d,B such e.k himsclf or hcr*ll or rimulh hk or hcr o*n cmplorcs.
<br />tmridcd rhnr .uch imtmmnrs d dn inr.nd.d .i olTcrtd for eL. Il hdwcv.i 0E huildirB or inlmrcnrnl h sold within onc ,@
<br />oi corpbr ion. thc Owmr BuiUcr will hovc ltE bur&n of,riovinB th.r hc or she dil nor lriLi or idptrrw rhc rFFny ror rrE puqrsc or
<br />-1.$otrncrolrhcpopcny,amciclusivclyconrrlcrins*ithliccnsdcoirrlcr(trsr..otr{.rrhrn4!rlscc7()44,Bu$ms\and Pmlixsi. Codc: Th.Conascrx s Li.rn* I-awdo.s or stply r. ,n ownfi o l [o0cny who huilds or irrovcs rhcrmn.
<br />and who..nrrndslbrs.htojrclswiih0Onrtucto(tltutrcdpuru.nrrorhcConrrador'sl-iccnsclju)
<br />-l
<br />m crclnpl undcr S6lion-- B. & P.C fo, rhh r€.son
<br />IJllr (hner
<br />trattr!&rrauuliarrQ!DE!! .BrIIIQN
<br />I hrr.hlrfftrundcr Nnrhrolp.rju,!uncotrhc tulk'wi',s Jcclxrinnn
<br />-l
<br />hovc an sill minlain a Ccnificarc of cl,n*nr to Sclf-lns!rc for wortcN .odrcisa'ion. I pbvid.d lor by Sslion 3?00 of lne
<br />Llbor tue for lnc psfornm of lhc work for which ltc Fmil h issucd.
<br />I hrvc rnd will minrain *orkcrs' compcnsrion insuhm.. d rcquncd by Selion 3700 of lhc tibor Codc, for rlE p.rtulM* ot
<br />lh. mrk lbr whicn lnis Frmil is issucd. My wort6 comp.trsslion insurun.c caricr e.d polic, nlnbcr ml
<br />FIc,"r., sM\{ ruvl(,^
<br />Q>,r1356t -7 !)tz
<br />-l.cniiythrl
<br />inthc pcrrbrmoEc.flhe sork rb.*ht[ rhis!.rn r h nstrcd. Ishsllnor cn'fk,y any p.ra,. ina.t'nrnrcr
<br />q, os b r..on* subjccr b rhc wolk${ ..mpcnsdion lawr or Crliroiiin. ldUNrln ifrshouklbcconEsubicrrornc
<br />workcA.onncnun,nlf.vhi.nsofScrt ]Tmof rh. tjtxtr C.dc,l slull, fodhwirh.onr/y with rhos trovision\
<br />S.criotr:lr)76ofrh.l:ltnrCdlc i,ncrcd and ,rronf,v \ lics
<br />o"", -7125 ll\ o,o,,*",,.W Cll
<br />DECIdNAIIA!
<br />I hcrehy aifirmunder pcnaliyotpcrjury rhsr I E n lienaal under,n(,viion drChspr$ 9 (sfrn.ncing wirh Scclion TuxJ) ofDivnion.l
<br />ol ttrc Brsirc$ atrd Pmlcsions Codc. ond nry liccnsc n in full rblcc md elfd.
<br />l0 l-13
<br />-7 t25/ I ?)dllt\
<br />g)NiraltcIl!]NTENDINli"Ali[Ncr
<br />I h.rby afln'n und.r Fnal'y of pcrjury thar rh.rc n a co.slfldion tndinB ngcrcy tor thc l,crfornnrcc of rhe wo.L ru {hih rhis Frmn ic
<br />hsocd(Sec 1097.Civ C ).
<br />L.nds . N,m
<br />-
<br />l.cnifythlr rhc tadcrul rcgulllions rcBnrding ush.sros rcnmulec nor up,,liclhl€ ro rnis pDixr
<br />@t "*ity,ho, t t'o,","ua,lk ryrlicarion ud srars rhar rhc lbovc irlonMrion h cotrc.r.I asre b c$rtry wirh a cnya.dcontrty
<br />odinsrc.s .nd Srorc t ws elarin8 ro buildiflS consrddion. at lrcrchy adhonzc rcprcsc nrar iv€s . f thh Ciry Md counly'o cmcr ulDn
<br />'lEnh'vc nrnrn cd pmrcdy for instEtiotr pulx)scs
<br />lb,ll(J
<br />Appll.dl or AB.rt Slgn,loE -
<br />P"*ir* nu-" rpanrt, Zrll
<br />D",. a/26//s
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Bonding / Grounding / UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof To p Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilinqs (Hard & Sollit Rouqh
<br />Ceilings (T-Bar Rough)
<br />Rough tr/rtl z S\ E6
<br />Service I\/eter
<br />FINAL 1/ilr.1 s\(/q
<br />Notes, Remarks, Etc.
<br />ELECTRICAL.INSPECTOR RECORD
<br />W RNING: Failurc ro ecurc wortcrs comnctrsiti(,n covcra8c is unlawiul. rnd shlll \uhjccr un cnpl.)d tr di'nitul FMkics dnd
<br />civir rincs up to onc hunnrcd rhousrnd d.llan (S1(xJ-000), in nddnion lo
<br />'hc
<br />co{ ot con1l*nsari.n. dr r8cs ,s rovidcd lor rhe
<br />AIPITIAII.DICI.AAAION
<br />I hcr..tryufimundc! renrlr, ofrsjury oM orrh. n,lk,*ins dsle ion\:
<br />DcnDlition Pcnnits-Asbcsros Norificslt,n Ftd.ial Rqubriofl\ (Tirlc.{0- Pun6)
<br />-R.quircd
<br />Lcltcr of flotiarcalion
<br />Pole Bases
<br />Under Slab / Floor
<br />Meter Belease
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