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APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDEI{ DI]LCARAT('N
<br />I hcrcht alrirm undcr Fnrhy ol pcrjury lhd I on cx.mpl tiom thc O,nlructoN Liersc Liq lor rIr lollowirS rcd$n (sc.70.ll5
<br />Busin.* and P,.lcsi.n Codc) Any City or Coutrry *hi.h rcqtrirc\ r pcnnir b con(ruct. allcr. imrrovc. dcflblisn or rc,,in aiy
<br />strlcrurc. rn,rr. ns is\oancc. alw.cqunc\ rhc {Ili.ad tur su.h Frnrir r,liL r \iENd nlrcmnt lhar lEor snc h li.cnscd punu!
<br />ro rh. tn,vhn,n\ ol rlE Conrra.rols Li.c.$d tr* (Chtrprcr 9. Conmcncins wirh Sccrion ?uD of Division I ofrhc Busnr\r md
<br />hotcssi(,ns codc).r rhrr hc or shc is cicmpl lheairom lnd rh. bzsi\ fu thc,llclcd cr.nlPrion Anyviolarionofsecrion?0.lt 5 byrtry
<br />atplicanr ior i lcrnrir subrc.B rhc rmlicrd r, a.ivilI)cn(lryofnotflrcthrtr iivc hundrcddottars(!5OO)
<br />-1..s
<br />oqkr of lh.tl(,Fny, or m, rfrplores *irh *0scs as rhct $r.comlcnsarion, willd. rtE *ok and rh. {turh n mr
<br />inrcndrd or oitcred ior elc ( Se.7u4, Bu\in.s a.d P,ofesiotrs Cndc '1 hc Contrd.is Liccn$ tjw d.rs nol .pdy ro dn .sncr or
<br />thc pmlEdy who brilds or in!ft6 rhcNn. od who d(s 1kh tulI hihsclfor h.rulIor rhrougfi hh orncr osn cmployccs.
<br />providcd rhd such inpn,vc'rcnrs rrc nol intcM.d or ofcftd lbr qlc ll hxcvs. rhc hui&lilla or nurcloEnr i! r,U airhd mc ycitr
<br />of.otr!|)uhn. tlEOwnq Builtcr willh!v.lhc bturd.n oftmvina thal hc or shc dn nol hild or impr.v. rh. pnrFny for rh purJ,$ of
<br />l. ff .wtrr .f rh. Ixrpt y. !m ciclusilcly conlrNril8 wirh liccnrd comBcrn\ r0 connrucr rh€ rnjsr (scc ?01,a. uusrnc$
<br />rDd PhL*ri{rnCodr Thc(i,ntacror'sl-iccnsclisdmsnorapplybrtrotrnrorpnrpcdyshobtrildsorihprovcsrhcrcon-
<br />and wno conrr.cls lhr such pmjsls with , Co.hcrtrG) liccnrcd puru.or ro the Corr.dols Liccnsc bwl.
<br />B & PC forlhn rcasn.2U-lp<ta-:*io7 f1 4s
<br />I hcrchyrfliflnrndcr prn!lryolpcrjuryoncoirhc n,lt(,wins dcclurtion\:
<br />l hlE! willm.inr0inrCcdifi.urcofCon{n oScll,lnsuErorworkcrJonp.n\m6n.a{pblidcdtorhySccrion:tT0Ootrhc
<br />Labor Codc.lor thc lcrfoanmN ofthd work nnwhich lhcNrmir is issucd
<br />I hav. rnd w,llmaintri. sqters. conrpcnsarion insurrn.c, rs rcqoi'cd hyS.dnri:r?00ollhc Lihor(.()dc. iot rhc F*rlormm.of
<br />rh. work fushichrhis pcrnrir i\ isml MJ- q,or*sj compcn\arion in\uramccrdcruJd policy nunrbci rcl
<br />Pnl'c) Nun$s L\Irn..
<br />I ccniry lhal i.lhc ptrioflmncc otrhc work ror which rnt t'cflnir is hsucd. I sh0ll not cmplov any pt^on in a.t 'hrnmrb as ro bc('tu iubjccl k,lhc wortcrs q'nlltrn$rion l,wsotCaliiorni!. ud uEc rhar iil should nccom slhjccr ro rhc
<br />*ark.n..mtnsari{nrpmvisionsotSccrionlTmorrhclnhrCodc.lshllltunhwithcon{lyqilhrk,*pmlhions
<br />IyARNING Irrdurc h s.urc \eorkc,\' ro covcrrgc is ntrhqtul, rtrd \hrll \uhr..r nn crplofr k'.nminrl licuhi6 rnd
<br />civil liocs uI lo om hund(d lhousnd dolh l(Xr.(NI)). in addirbi l. rhc .orr ol.o tcnsarion, danjrgcs rs nnviJcd f{r rh.
<br />S(r(tr, l{)74,n thc t-rlir Cod.. ir car x d
<br />-A/z*a".,",t2/t*f ts
<br />DUAAAIIIIN
<br />I hsclryalfir undtr |xnllryofpcrjury rhll I om [ccn$d undcr Fovhion orChrpid.9 (commmins with Sdion ?Ol]O) ol Divhion l
<br />or rhc Blsirc$ and Prcltsions Codc.ond nrylkchac is in aull{orcc 0 clTect.
<br />CoNSTRTI(]TI(IN I FNNINC A{:FN(:Y
<br />I hcEby aiinm undcr rnrkyorp.rjuryrh{l rhsc h 6 oNlrucli.n hnd,ne agcmy ror rhc p.rrdturc orrhc krk for {hth rhis It mil h
<br />issucd isc...1097.Ci!. C ).
<br />APPI I(]ANT NF(]I {R"{TI(IN
<br />I hod,yNrlmunderFnrlry oi lerjury onc ofthc follo*ine dcclualions:
<br />Dcmlilk,n Pcrmirs'Asb.sos NodrEalbn RdcEl R.slbtions (Tillc 40. P0n6)
<br />R.q!ircd Lerrcr of Norilicorion
<br />y Pnh.ll Cnyrnd (ontrlt
<br />ymd Counlyto..lcr upon dc
<br />-l.cnift
<br />thar rhe ltd.r,l bgu hr ions rcsrdina $bestosrcrmvd e. not arpli.ablc ro ihh pDiir.
<br />-l
<br />ccniry rh.r I h.!r rc(l riis lppltarion en nar. rhd nlb!€ inao,nErion n corer.I u.e ro conDl
<br />mditun!.c 3nd srare li{r rbritr&ro buildinS !nn{ru.rhn, ird h(nhyaurhndc rcllc{nklncs otrhN Cir")*).|*'ir^I*.-)[)]2ub.u-
<br />- il.
<br />""*u** ",onnu, rf '7 L,c,4.4 Dra"r,
<br />or e ;/t9
<br />Site-Work
<br />Underground
<br />Poie Bases
<br />Li ht Standards
<br />Spas, Pool, Fountains
<br />Lile Salety /Low Volta ge
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bondi ng/Grounding/UFER
<br />Transformers
<br />Roof To E ul ment
<br />Factory Wired Unit
<br />Walls Ro h
<br />Ceili Hard & Solfit Rou hS
<br />Ceilings (T-Bar Rouqh)
<br />)
<br />Bough elsltg I-urrx-t-'{z>/
<br />Service lvleter (t I/'\
<br />FINAL tplt;hl')itn*A ?4)
<br />Notes Remarks Etc.t ul
<br />ELECTRICAL-INSPECTOH RECORD
<br />Siqns (monument)
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Walls (Conduit)
<br />lvleter Release
<br />bnder'r Addrcs _
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