|
APPROVALS DATE ID/SIG.COMMENTS OWNER AUII-DAR DEI-CARATION ',
<br />I hcrchy aflirm under pcmlry or pcijury rh.r I un cxcrq, lnnn rh. Conlraclon t-itc e rjw r(x rhc followiry rcK,n ( se. 70 ] l t
<br />Bxsind* rnd Prolcsion Codc) Any Ciry or Counly which rcquits { ,.rnir lo construd- altcl inDrov., d.n.lish or mprit !try
<br />stru.ruc. Dri(trlo irs hsurnce. al{o rqunc{ th. arpli. r ror su.h Frnril ro filc r siEned darcmn' rh,r hcot sh. t licctrkli Puriua
<br />ro rhc tbyisroN olrrE conracr.rs l,iccn\cd li* lchaprcr 9, Conm.m ! $ilh Scclion ?OOo of Divhion:r ofrhc Busi"cs ond
<br />Pnlcssiotrs Cod. ) or rhII hcorihc it.rtnrpr rh.r.aronrand rhcbasi( tor lhc allcEcd cxcaprnr Any violaiion ofSccrion 7Oll5 by rny
<br />apllic0trtioralrmirul'jccrsrhcappli.anrkn.ieilpc.,!lyoltrotDrorclhannlchu rcdd.llars($5ur)
<br />l. N osn.r of rhc l,otEdy. or trry cnrphrtes wiii w{gcstr\ihrir slc c.mp.ns ion. willd. rhe work,nd rh. {tu1uc is mr
<br />inrcD-ld or olltred hr *le (Se 7(D4, Busilrs ad Por.*ioN c.ds l-hc Conlnctoi s Li.e.sc bw docs nor aPply to !n oen$ .f
<br />rhc rmtdy alx' bdlds or nq,mEs llEen. !d who dcs $ch w.t ninNclr6r hd{lror rh$u8h hh.r h€r oM cnr!.y.cs
<br />providcd Ihar such i.lrmkm.rr re mr inrc ].d or oll:Ed fnr {L. Il hoscvc. rhc ttrilding ot impmv.'r h$ldsilhinoncru
<br />of.omlhiion. thc Osncr Buil,&r *ill hlt rhc fiunrci of tnrvnB rru( h. or shc drl nor ttrild or iryrok rhc pmFny ro. rhc nuq'os ol
<br />-1.
<br />{s oBncr ofrhc nropcny. adcr.lusivcly.otrtichS wiih li.cnscd conrrncrqs r, con{tucr rh. projNt (Scc. ?01.t, Bu\iru\,
<br />Pir)fcsssn codc Thc Conrrncr.is l,iccn\c l-rwdocs nor rpplyb m o{ncr of pror.ny $ho hDildso' nnp v.srhcrcon.
<br />rnd *ho conrmh ri,r srch pr,jccG wirh!ConrnctSsi li.cnscdl)Unurni h rh. C(nnndofs License ljw)
<br />_l mcxenrpr rndcr sccri.n ,lt &l'C lorlhnrQsn
<br />Dole oPner:
<br />WORKF.RS' COMPf, NSAiItON
<br />DICI,ABAIIO!
<br />I turcby otli.nundo pcnrlry oa N'jury oR olrh. rollowin8 dcclmrio.s:
<br />-lhrvcaxlwillmainloiraCcnilrdrcofconscntlosclEl.surcfor$orkcrs.o'npcisaridn.asProlidcdfo!bySalionlTu)ofrhct2lror Codc. for fie pcrlo.mrc of rhc work ior which rhc ,rnnir is hsucd.
<br />-l
<br />luvea0d sill Einrlir trork.( c.nr|rtrs,rion irsu6ncc. ar rcquircd hySccln,n.lTu)ofrhc tiborCodc.lorlhc lcrnnnMcc.i
<br />nir h\Nd. My workss s,npcnslriotr insu$L_c .arhr Lid !.li.y numbct trc:
<br />,ttt,
<br />(,(,t
<br />I .cnify rhrr h rhc rcrloirnrn.c otrh. Nork ai, *hich rhn Fnnir is i\\ucd, I \hnll mr .mnby rny ltnotr nt ntry mrnncr
<br />b b bccom s.l,Jed tu rhc soA.r{ coiqEnsario. has ofcalilonri( and a[m rhrrifI sh,uld tNom suh,ecln, rlt
<br />so.tcr\ con9cnsrrion pnrisn,trs olSdion l?00.frhc Lahtr Codc.l \tBll, f(rrhwirh conrPly wirh llms trovi\i{,ns
<br />IVARNINC: I
<br />sc.rr,n,,A,,
<br />rrarr: l
<br />0lurc ro rcur. rukcri con,t n\rri{n .o\rruli unlutrlirl. .n,l \h
<br />ni orc hundrcd rhou\and d.llrr\ (51(n.0(X)r. i'r ddirio lo th. .o(
<br />, rh.l rtin a{xlc inrcrc{ Md rxtu! \ fud\
<br />.b.lou.
<br />I h.rchyrlfiirnrnd.r poMlrr o r Fijrtrt rhd I nliccr{alun vnioiol Chrtrd9{.onnNncirs silh Sccri.n 7{xx) orDivtn l
<br />oi l[c Ausincssond Pron$n r Cod.. r nry licctrN n
<br />b-Q \ooqc<<.t6s Vqk't'''
<br />caNSIf,U!:UrAIENDAGrrcExq
<br />I hcrch! ailrnr undcr lcnalryolpcrj!ry rh rhco is a consftrbn Lndirs rBcmy (tr rhc Pcrturnran.c orrhc qort for *hich rhn If,m i{
<br />issucrt (se. 1097. civ c )
<br />AIILICANLDDI;L/8AIIgN
<br />I M'yiillnnund$pcn(hyof pcrjuryone ol lhc {.1n,*ins dcclsarions:
<br />&nrlnion Pcrmirs Ast ros No'ilicatio. tcdcml Rqulot ions (-l ilL 40. Pan6)
<br />-R.q
<br />ired litrcr.f Ndifrtriotr
<br />hnr lhc lidcrrl rc8uhrions aCaili0E r\h.{o\ r.trxrrlnrc trrr rt,plic{blc lo thi\ nric.r
<br />ilythrr I luvercod rhisaptli ion salclh rhcrl!'vc i[conlt'ly Nirh allCirynnJ Cou ry
<br />nccs $d SrorcLau! rclatingb huildihtcons { dnc\ ofrhi\ Cirv and Counly ro.nr.r rF)n rhc
<br />$ovc nrnrioncd prcpe ylor iirspccrionpu
<br />:\pplicsnl.r ABenl SignstuR'*) h:-->,
<br />4c.to+
<br />Site-Work
<br />Underground
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Building
<br />Under Slab / Floor
<br />Bondinq / Groundino / UFER
<br />Translormers
<br />Torqueinq
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilinqs (Hard & Solfit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />It/leter Release
<br />Rouqh //'2,< tB /1?r,
<br />Service lVleter
<br />FINAL Dh/rx ))5v
<br />Notes, Remarks, Etc
<br />I
<br />ELECTRICAL-INSPECTOR HECORD
<br />I .r'lc' \ A'ld'...
<br />-
<br />Pole Bases
<br />Communications Cable
<br />Sub-Panels
|