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APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDER I}ELCARATION
<br />I hcrcby oilnm utrdcr ncnolry (,1Eriury lhol I @ crcnpr rmo thc an rn ron Liccnsc Los rb! rh! n'lh*in8 rctrv,n (sc.70r! 5
<br />Busincs and ltotcsn,n Codc): Any Ct, dr county whi.h rcqurcs 0 rEnnil ro oi(ru.r, &lr.r, impovc, d.mlhh or rFnn lny
<br />{tu.rud. pri,tr Io irs isu.m., ako rcquircs lhc !F lkatrl lor such t'cflnil to filca signdd sdc'ftnr rh.r,tor shc ( liccns.n lursanr
<br />lo the ,rovhions oi thc Gnlrackr'\ Liccn{d trw (Ch,fl.r 9. Commming wiih Scclion ?fi) or Division :l of rhc Busi.c$ lnd
<br />Prollsi,ns Codc)orrhar h.orshc iscxcfpr ihcrciron ond rhc b,sh lor thc nllesed ncmprn,n AnrliolarirnolSccrhnT0ll s bysny
<br />,ppli.,nr rohFrmir subjeh lhc {!lic.nr to acivilp.nrlryofnor morclnrn fivu hu.drcd dollah ($500)
<br />I. $ own$orrhc pmpcny. rcxclusivclyconr,elirEwirh lift.sed contnct,F lo co nstrud rhe loiccr (S(.704.{. Bu$.$
<br />aM ft,ns\hn Codc: Thc Conrrkrn\ Lic.nsc tlw d@s nor aF ly lo nn owncr or propcn y (rb build\ or irnprores lhcrcon,
<br />and who.odachlnrsuchprcjcdswirhrConrraclorls)liccn$dl)u6odrrorhcCtnrdolsLi.cn*L.r)
<br />lJdcrc'nDr undn Sernn .B &PC fu' rhi{..Drotr.
<br />lr}8trE8li-lau8lNs I(,!
<br />D[C!Af,^]]O!
<br />I hcrcby rifirnr utrdcr pctrrllyorperjry onc oirhc t(,llo$i',8 d(lararionsl
<br />lhlvcu willnui nin0Cerliicurcolc.n* r h Sclt li\utu or sorkcr' comFnsar bn. !\ pDlidtd ror bysNrionlTLxJorrhc
<br />tjtx, cod.. rrtr rh. pdldnun.c ol thc work for whi.h rhc Fnni n i\iucd
<br />I hrrcrnd qill iinr&in $orkcricon,tcnrari(,n i'sutuN.. Ds rcquncdhySerionlTU)ofrncLaborcodc.lbrrhcp.loflnrnccol
<br />lhc wort r'orwhichthis pe,mil is is\u.d My wurkc6'.onD.ns,'n iNuramc caricrontp.licy iunlbcr uc'
<br />Policy Nu'rbcr:-Erpircs:
<br />-l
<br />ccnilyrhur rhc !.rronMn.. olrh. *ork lor shich thh rcrnil h isucd- Ishrll n r cnDn'y 0ny pcmn in lny nMn r
<br />s a\ b h..onf, srbr{r b rlrc porkcn' comncnsal ion h*s ot Culifixnir. ,nd 4N $ar il I stFuld b.totu \ubjdr to rh.
<br />sork6' .omp.trs,r io. povnions ol Sdion l?(]O of rhc litr r Codc. I \hall. rodhwirh q,nply w ilh rk)s Pmvisio.s
<br />Appu@t:
<br />UCEUSIDIANIBACIOB
<br />IIECIdIA.IION
<br />I h.aby aflisxndcr p.nnxyorFrjury Ihrl t a liccnsi under pmvhion oaCh:9r( 9 (.omming wilh Scclion TUIO) of Divhion l
<br />ol lhc ausircss .nd Pmacssio.\ Cod.. trl Ey li.cnsc is in rull rom dd cllccr.
<br />coNirf,lrqr0NrlllacA!,iENct
<br />IhcEh,lmrnund.il*nllr,orpcrjrrylhalrhcrch!con\ldcrionlcdin!o8ctrcyforlhclicrli,nunaoarhcworkrorwhichthisFirnirn
<br />kuc{ (Sa. :ll r97. Civ C,)
<br />AEUgANIDECIdAAIIA!
<br />I H'yInim uidcr pcn.lry of pnjuy onc of thc iollowitrS dccllnlionsl
<br />tlcmlilion Permirs Ash.sros Noiaricarion Fcd$al Rcguulions (Tillc40. PEl6)
<br />-Rcq!ird
<br />trtrcr of No{fution
<br />-l
<br />enifyrhsr rhd rcdcml rlgullrions ES.dnrs ssbestos rcn]vll {c nor amlh,blc ro lhh Pml$l.
<br />l.cnify Ihar I hr\r rcrd rhh
<br />ordinan.cs Md SldcbwsEbli
<br />d rhcabvr infdoufion i\.otrcd I ]gr( b.rmfly wirh rll Ciry a.d Counly
<br />outhorizc rcnrcrnulivc\ oarhir Cnylxl Counry lo cnrcr uPor rh.
<br />V
<br />Lleerr(anr
<br />,, al ntlt Yt6 x*bJ ill\
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Satety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Bonding i Grounding / UFEB
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinos (Hard & Soffit Rouoh
<br />Ceilinqs (T-Bar Rouqh)
<br />It/eter Release
<br />Rouqh
<br />Service lvleter
<br />FINAL 6 -/{-/A Jy'e{*{q,r)
<br />Notes, Remarks, Etc.
<br />ELECTRICAL.INSPECTOR RECORD
<br />Site-Work
<br />Under Slab i Floor
<br />l. * owncr orrhc,,spcny, o. nry.tr[lorrcs wilh wascs ns lhcn sb cor\rns,ri(,.. will do lh. wolk fln tlE sltrr@ ir mr
<br />n cukl nr oficrcd for elc ( Scc 7l)tl4- Busincss and PhL\rhnl cod.r Thc Conltactrt Liccns b* der not onrlv lo .n o*ncr ol
<br />rhc pmFny eh, buirds or irroEs rhcFn. ai who dtrs sh so* inns.lror henellor liolsh ht or h.r owi.mployccs,
<br />,rovidcd lhar such impmvc'EnrsN nor itrrctldi orolreftd rrtreL.ll h.wcE,lhc huildinBor impmtftnl is$ wnhinonc,u
<br />oi cotrq,hri.n. rllc Owmr Blild.r siu h,\r rrr h{r&n of pb\in8 rh0i tb or shc dil rct huikl or ihP$k rh. Pmttry for lh. ,)ur!oE ol'
<br />llARNNe l,oiluc h surc k c6 .o'np.n$tion (,vcrsgc is u.hwful. and shall \!bi.r m cmplorr ro qiniMl pcuhics and
<br />civil fincs ur ro om hundrcn rhou\and d.llus (Slu).ofi)). in lddirion ro rhc cod ol.otp.n$rion, drnE8cs os providcd for rhc
<br />sdion]0?6 otrhc ljhn c.n., idr.rc{ ind MonEy s fes.
<br />Co elor:
<br />Lcndci\ Add'.s
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