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OWNER BUII,DER OELCARATION
<br />I hcrcby afltn undcr pcnahy of FrJUry th.t I m cxcmpt fio rlr Cofta.ro6 Lic..sc tiw lor rhc lolbwin8 rcasn (Scc.7o-l 1.5
<br />Busin.s lnd Pmlession Codc): Any Ciry or Couly whicn i.quircs . Fxnil lo con(rud. 0llo. i nrorq dcnDlhh or rclon lny
<br />$ru.rur.. pri, b ni hs&kc, dso rqun.rrh. rlplicur Io, such pcnnirb filea \i-s.cd {arcftnr rhat h..r shc L li.cnscd pu*omrr
<br />b rh{ provnions oflfu Conr.ocror's Licctr\cd L!* lchlplcr 9. CoNncncin8 slth Scclion 7tx)o ol Divhn,n I or rhe Atsin.s !.d
<br />Pofc$io Co.l.) or ihdr hc or shc i! crcnrfrrh.rcfro'n d rhci!\i\ rq rhcsllcBcdcicnprion Aiy vi{nrrionofs..rk,n T0ll S byrny
<br />lrrpliconr lor! pcrmit subjsls rhe opplica ro acivilFcn,xyor.or nrrcrhatr rivc hundrcd dollarc I Ssm).
<br />l.*o*ncrotrhcpn,pcnr-ormycdrk,,E\*nh*!sc\a\rhetslccoDrlrnsrion.silldorhcworlr rlE{turmi\' I
<br />iclcdorolldrcdr{nslc(Sr70,1-4.aus.crsaidPmlc\\ion\Codc:lhcCoirrck"\LiccnscLi*docsnorapfltroai.vnfof
<br />rhcprcIlcny who hurl.Ls or i.DroEs IhcNn. ntrd stu, des $rh so* hnnsclr or h$scll .r lhrouBh hn or h.r own cnDloyces.
<br />provid.d ih,r nr.h n pmrnrnrs d nor inrcnn\l or ofttBl ir eh lI lnrwcr.r. rhc tn)ikling or iwrovcnrnr is {,kl wirii",
<br />'c )u
<br />of.o.lplcri{)n. rhe O-mr Buitld will hrk rh. hurrhrorpmvirg lhar h..r shc dil mr hilt or iq'rotr rllc prcpcny for Ihc puqi,{ol
<br />-1.
<br />n{ o*ncr .r rhc trcpdr, an .xclurivcly c.nt,.rin8 wirh riens.d .onLnct r i(, .dn(ru.r rh. pn*.r (sR. 7t}1,1, Bu\ift$
<br />anl Pn)f..sirn C.dc: Thc Contdcttr r l-ic.nsc ln* doc\ nol aplly b 0n owner olproFny wh) huildr or inpmvcs rh.ft.r.
<br />lnd {ho conrachforru.hpmjcdswirhtrContac!)(s)lic.n*lputrurDrhthcC{n rmlor's Liccns lis )
<br />I rnrcrcmd undcrSc.riM;" ,81a 14
<br />D&CLIAd]IAN
<br />I hcrchyllnnnutrdcr r. rhyof ncaurynncolrhcn)lbqhr dcclararnnl
<br />I harc al ,ill nuinruin o Ccnilicarc ol Con\cnr loScll-lnsuro rdr sortd f comncnsorion. as prcvidcd ntr by SE.'rion:r7(I) olih.
<br />L$or Co]c. rbrlhe lcrformrcc otlhc wo lorwhichlhcldn istsucd.
<br />I hrk xntl will n,trinrrir Nolkcrs compcoszrion innmrcc. ff rcquircd t) S$r ion .lTlr0 ot rlt Lf,txtr CoJr,lirr 'lt
<br />pcrtonnrn.c or
<br />rhc *ork f{n *hici rhisli.rnrir is n{cd Mv*orkcr'conrp.trr.tion nNurrocc crnicr ml policy numbcr @:
<br />Poli.yNumhcr:-
<br />l.cnilylhlr if rhc Dcrl'onrNrccolrhc work l.r trh'ch rhi1p.' rir ,r a{rc(1.I \hrllnol cnrployrr} pcis n inrn}aranncr
<br />q, Nk, hccrm \ubjcd n,ihc wur[.^.onpen\dn,n lrw\ ol Crlin,mi]. rnd rgrc rh ill \ln,uld h.con{ \!hjl(rhrr
<br />*orkcr co rF--.ernnr lm)risioN of Scctn ]Tooofrhc Lhn C{xlc.l stu l. r(trrhvi(h.o rtly sirh rlb{ prulnnnls
<br />$ARNINC Flilurc ro scurc *orkcr'conrpcnsarion 6v.ri8c is nrlflwhl. a shnll q'blc.l !n cnDlo)q b qi,ninalItuhic\ .l
<br />,.,",-8
<br />. otr. hufdftl !hou\xn,l (lollrr\ (Slolr mtcNnrion. dlnugcs !r nroviddd ntr ih.
<br />l21l /s^
<br />tr( t.,\R,\ I t(,\
<br />I hcEby rmnn und pdnnlty of pcrjuiy rhr( I am li..n{d rndcr pmvi\n r of Chrrrd 9 l connrn.in! wnh S..th 70UD ol Dn ni l
<br />of rh. Busin ssdnd Pn,f.\in BCodc.od Fy liccne i\ in liillli)r.! url ctr(r
<br />Dsler corlrrcto.:
<br />CONSTRUCT(IN T FNDIN(; AGI-NCY
<br />I h.rcby affirm undcr lEmlryofpcrjuryrhai rhsc n a.-ndrucli,n lcndin3 olcncy ftrrhc pcrfofl,Encc ofrhc qork lor whkh rhn p.nnir is
<br />nsu.d (Scc.109?. Civ C ).
<br />APII.ICANTDDIIABAIION
<br />I rrE+,y dfum urder penalty o, Frjury orc oilhc hllowins dcclorarions:
<br />D€mlition Pcrmirs-Ashcnos Nolilication ftdcral Rcauhtions fillc,10. Pon6)
<br />-Rcquncd
<br />Letrcr of N.rificorhn
<br />I ccdii) rhar rtc icd.rnlrcEUlnrionr rcgrdin8 ashcsros
<br />I(c'r'4 'hJrIr$, n'rJ rl\Jffl'. rntrJhl{rh'rl' rhc
<br />rcnDralnrc nor lPplicablc io rhispmjccr.
<br />rtxrc inr{rn*rnnr's.orc.r I ll8hroo'nply
<br />xl hcrcl'y aurh{rik rcp'.\c rnrivesorrhkCntfrditun.cs md sl rc Lrw\ rchrinS
<br />rhn. nf,nriinrri I,oPcnvtrtr
<br />'\lpli(nnl or \!onr Si!tr,lurc
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Satety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />To rquerng
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilinqs (T-Bar Rouoh)
<br />It4eter Release
<br />Rou gh
<br />Service lvleler I r L- t,c
<br />FINAL L Nlt'l'o .,F,zv
<br />Notes Remarks, Etc
<br />EA
<br />D
<br />D.te:
<br />rtrd Crutrl!r,.trro uD!r rltr
<br />ELECTRICAL-INSPECTOR RECORD
<br />Transformers
<br />t-iccnsc Chssr l.i.oi\. Nrn,h0
<br />Lcnd.r'.
<br />^ddrcs
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