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APPROVALS DATE ID/SIG.COMMENTS OWNER BU!LDER DELCARATION
<br />I hcrchy .ifirm undcr p.naxy of lfr.iury lhd I m ex.rli tFd rh. Con(F.ioN Licc.s. tlw ror rh. followin8 rctrsn (S.c 703 1 5
<br />Busincs ,nd Profcssion Codc) Any City or Counry which rcquncs N F rnit lo $nstEct. ,llc( im0rove, dcmlhh or arEir any
<br />srtuclure prbr lo ns hsuotrcc,oho rcqutcs thc arplicanl for su.hpcmi ro nt o siemd st cm lnol hcorshe is liccncd plruur
<br />ro rh.,ftvi1ions orrlt Conka.bfs Li.cns.d Ll* (Chrrrer 9, Commn ing wirh sc.rion 7000 or Dirision 3 of lhe Busincs and
<br />Pmacssions Codc) or rha' lE or shc k cxcnFl th.rcfom Md lh. bast for lhc alhScd cxcmplion. Atry eio,alion ofScdion 7011.5 hy otry
<br />^
<br />smlEanr ir d |(.nrir .uhFcrs lh. lrnlic,nr ln a c.v,l Fnak ) ol nnt mE lhatr lirc hundrd d,,llu .
<br />'
<br />$n0 r
<br />zflLl a. "*ncr or r rrc nmnny. n, my cmrlnles w h s+cs .3 rhcr src .omp.ns i,tr. w,ll do thc sck and rh$rnErE i\ mr
<br />' inrcnJcd .r ollcrcJ fir qk lse T044, Au$.c( snd lrotcsion\ Cods The Conrru.ktr r Licc.s ljq rtr. nor nmly h ar owftr of
<br />rhe pmrcrly aho builds tr inDrorcs lhcE)n. md who doB $ch w,lk hiflselfor h.isclf or lhmusi hh or ner own cnrrloyccs-
<br />[ovidcd rhar such impmwmnls e mr inrcndcn or onarcd for .oh li: ho*crcr. rhc hildin8 or trymwmnl is $ld *irhin otu ,tr
<br />ol complcrk'n. rhc Oencr Builds wiu hlve lhc burdcn of Imvin! rhd h. or shc did mr hoild or irrmE lh. pmFny lor lh. pu4Dc of
<br />l.n\ow crorrh. nmFnr. rmcklu\ivclr.onrracrins sirh liccn\rd conrr.tn t, .onntucr rhcti(id (s.. 101,1. Btr\irf,s\
<br />r l Pml6sirn Codc: Thc C.nka.ror's Li.ctr{ Ldwdoc\ trorit,tlyb nuwncr.ffrrpc y wh. huildsor irn!rcvcs thcrcon.
<br />rid sho conrrd\fttr\uchptru.cr\\irhaconrxctf(olietr{dpunr t)rhcconkrtrr\ l-iccn\c lrsr
<br />IaItU b
<br />I hc.chy nlltDr trndcr |tmlr, olr^--rtury ofu ofrhc lallt)*i',p dc.lrr
<br />_l holc and will mainbin wo*c6 comocnsalion insur.Dcc. rs r.qurrcd h, Sdion 171)0 olthc Lahor Codc. forlhc p.rr.rmatuc oi
<br />ihc uorl for *hich this pcrmil is issEd. Myworkds omFnsaliotr insumrcc c0ricr ard !.li.y numher!rc:
<br />qfrI;'*ir rhc Frrorroncc ol rhc *or[ ftn which rhis pcrnri n i$ucd. I shtrll tror c pk,ynny ptr\on i. u y mnmr
<br />suhlcd ro rhc *ortcr com|f,trsdon lnws.fcnlinmia. aNl {eruc rhd il I {hould hroor subJcc o rhc
<br />trsolion [ovisiotrs oiSccrio..]7(Dorrhc bk,r c'odc.l drll lnnhwith comfly wnh rho$ pmvhions.
<br />WARNINC failurc lo *curc *o.kcn'con,p(nsdnrn covcDsc ir uDl!*1u|. !.d shxll \dbicr rn c rpr,y.r b oinnn,l |f,trrllis Md
<br />n, rhc con of.. Ern\rrn . danutcs rs F.ovid.n l{r rhc
<br />IirT{"
<br />inr.r{ rnd rnonryt lccs
<br />Applienl:a
<br />Ih.'oby lln tr, LnJ.' |{nrlrj_ 01p.riuy rhxr I rn li..n\.(ltrnJo',visi,n.lCh frc' 9(.onnr..nt*irhSccri( ?1IJOrof t)i\i!i!{]l
<br />.i lhc Busincs md Prcfc$ions Codc- and my liccnsc is in tul| rbre o'd ctlNt
<br />CIINEIf,I]CIIQNIINDING.AIiENCT
<br />I hcrcb, affirm undcr Fnalry ol r.dury lhd rhd t a con$dclbn hndinS e8cncy for thc ll<rlbrnge of lhc work Lr whth rht Fnii ir
<br />issu.d (Scc.1047, Civ. C.).
<br />AItLICANLDEIL/IMION
<br />I hcnby armn !.d$ p.tralryofpcrjuryom of$. followihg delarariohs:
<br />tlemlirion Pernils-AslEsros Norificarion Rderal R€sllarions (Tirle 40. Pan6r
<br />*Rcquncd Lerrc! o, Nolifi carion
<br />Ni;
<br />iJlrld lh. knchl r.!ulnri,rN togr nrgnslrno\ rc n^nlnr. do
<br />r rpILi.rri,)n rntlnrl.rhxr rltr rh,vd innnnir
<br />ahovc mnlioncd lrorcrl, lbr
<br />IvApplicnnl or AAenl Siamlure
<br />llii-l;,:ti':liih:1""'' ' + 'r'h\
<br />2Al tu, L/iilw*wt tc
<br />4r* to contrly wirh rll Ciryand Counry
<br />ivs orrhF Ciryond C.unry ro clcr uF'n rh.* akTl&
<br />Site-Work
<br />Under ground
<br />Pole Bases
<br />Light Standards
<br />SpAs, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Translormers
<br />Torqueing
<br />Air Condilroners
<br />Roof Top Equipment
<br />Faclory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />Meter Release
<br />Rough
<br />Service [r]eter I
<br />FINAL 6lzt ll5/ .4,/Jt7(t2./
<br />1NotesRemarks, Etc
<br />ELECTRICAL-INSPECTOR RECORD
<br />Sub-Panels
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<br />I hrlc nl $ill mrinrrin rCcnillcrrc ofConscnr r, S.li lnsurc for *ork. comlrtrsrrion. ^ Iln)ridrdf(trhyS..ri(fll7(X)ofrhc
<br />l-$or Codc- l'or rhc pcrlornnncc ofrhc worl lor which rhc rcflnir h nn'cd
<br />I-isnsc Clssi_Licnse N!mb.r:
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<br />Der. C.rlEdor _
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