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APPROVALS DATE ID/SIG.COMMENTS O\T'NER BUILDER DELCARATTON <br />I hq.h, Emon und6 pdahy of rdjlry rhal I an .rcmpr lior rh. Conlmclors l-ic.nsc Larv lor lhc tulk wing r@n (5...701 1.5 <br />Busin6s and PDf6ioh Cod.)r .{ny Cily or County shich rcqun6 ! pcmn to coBtrud. alrd. improv€. rldnolish or rcpdr ey <br />slrucrue prior ro irs isuuc.. aI$ rcquir6 rh. ip!,licaor ror such p€mn h fiI. , 3isn€n *ah6l thd n or shc G licds€d psusl <br />lo thc provisioG of thc Conkacroar Li..ns.d Law (Chafls '). Com'n..cii8 *nh serion 7000 of oiviion I oflhc Buind ed <br />Proa.sioB Codc) or rhar hc or sh. is cxmpl lhs.6om ed lhe bsis for lhc allcs.d €xdption. Any vidldion ois&ion 701 L5 by af,y <br />opplicantlo.rpdmilsrbjetslh.applicanltoacivilpcnahyolnolnorclhdfiv.hundr.ndoldslX500). <br />-1, <br />6 oMq of lhE pmp6ly, or ny mplorc Nirh Nas6 6 rh€i. el. .o,np.Mion, \ill do lhe wort ad lh€ sln l@ 6 Nr <br />i.rdd.d 6r ottdcd tr s,L (Sd 704-4. Bosine dd Pro fsioc Cdc T1. Conlrocloir l-icsc LaLv do6 nol apply lo d osntr oa <br />the propdy sho boil& or improG ih€@tr ald pto do6 sch $!i( hlNelf or hdcllor ihough ht or hd om dDploy.6. <br />lrovidcd rh4 su.h improlomrs rc ml inloded q olls.d for sle I I howds, rhc hildins or irliwdml G $ld vifiin onc J a <br />orconplciioc rh. Ovn6 auiklg Nill haE lh€ tudo oflrovins ihd h€ or shc did mt t ld or i,rp,orc thc pmpdy hr th. prtpos oi <br />-L <br />s oMo of rhc ntup.nn m .r.lusi!.ly co 6c1ine sirh licaMd .onlractoB Io coBlrucl rh. lrej61 (5(. 7044, a6ins <br />md P,trfsion Cod.: Th. Conrracroas Lictr$ trw do6 nor.pply ro tr ownr olpropcnyuho b!il& or nnprcvs thsan, <br />and Nho conrra.ls for such rojds with a Cotnoclo(s) licflsj ps@r ro rh.Conlrcclols Lic.N. Lrw). <br />_l ,n cr'npt u.d.r Sor io6 . a. & P.( . lo. lhis rcason. <br />OBn.r <br />tlaBr&8l(lrlfEltarIa! <br />IECIAEAIIA! <br />I hd.by nmnn und.' I[ dllyol ltrrr ryonc ofrhc folld\i'rs dcclrarnnrs <br />-l <br />h.vc 6rd will iainrain a Ccnin.ar. ofcons( ro selfinsur. aor wrk€rs coop.nsalion, 6 Fovid.d lor by sdion I700 olfi. <br />Labr Cod., for rhc pqfom c. oarh€ Nork lor wni.h lhc Dmrn is i$ucd <br />I havc and *ill mdflain workerr com!.Nar ion i6uran.€. s rcquned bv Sdion 1700 of lh. tlbor Codc, ao. lh. !-qfonrecc ot <br />rh. work aor s hich fib Fmir is isuol. My work6 comp.Mrion i6or cc cui6 dd policy nunb.r d€ <br />Poli.t Nunbn <br />-Flpnei: <br />I co1iry that in Ihc p.rtomancc ofthc{o* aor which this r€.mit is isucd- I shall nor cnPloy any p.uon in.ny hanno <br />s, s ro bccone subj<r !o rh. roit6' .dmpdsrion la$s oacalia.mia dd r{r.. rhar ia l should b€.om subi<t ro rhc <br />*0*6' .onp@tion provisioN of Sdior 1700 of rh. hbor codi I stall, follhNilh co,nply * ilh thos povisions <br />WARNINGT f.ilur. to surc vork6 comptralion colmse is unlaslirl, ard shall subj..l m 4ployd lo siiin.l pduti6 dd <br />civil ,ln6 up lo on€ nundrcd lhouend doll6l$100,000). in addirion ro $. coe of conrp€Ntion, damas6 6 prorid.d foi rh. <br />S(rion r0,6 ol rhe L{bor code inled md itronF}'. 16. <br />Applidnl:_ <br />IICEIIINJAXItrAEIOE <br />DICIJAAIIO! <br />, hdcby 6ltm undd p.nahy oa pejury rh,r I atr liccN.d und6 lro!tuion of ChapE 9 (comm(c ins silh SdDn 7000) of Dilision l <br />ol rh€ Busins &d P.of6ioB Codc. ad ny lictu. is in lull foe. d efie.l. <br />CONSIRUCTION LgNDIN(; AGENCY <br />I h.r.byainm ndd p6alt, of p.dury lhrl thqc ir . connrudion lodins ar6cy lor lh. p6hlj@c. of th. sort for <br />"'hich <br />lhis pqmil is <br />issucd (S(.3097, Civ. C.). <br />AIIIISANLIECIAS{IION <br />I lE*y afrm !.d6 poalry oipajlry on ofOc aollowine dcleations: <br />Denolilion P.mireAsbetN Notificstion F.dsal R.luhtions (Tillc40. P6t6) <br />-R.quircd <br />L.rl6 of Notificalior <br />^ppli..nt <br />or Agol siCn ure: <br />Unde rground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Transformers <br />Torqueing <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 />Ceilings (T-Bar Rouqh) <br />Meter Release <br />Rough <br />Service lr4eter <br />FINAL t?,/y K Sbsa( <br />Notes, Remarks, Etc. <br />ELECTRICAL.INSPECTOR RECORD <br />Site-Work <br />L.ndd's AC4_s. _ <br />I .diry rhar (h. Ladsl r.gul,lioN r.gfldin8 6b6tG dnoral e nol appli.abl. lo thn Oroj.d. <br />-l <br />cdiry rhar I ne€ r€ad lhis appliorioo ai sralc $ar lh. abov. i.aomation ir corr.cl. I a8r to comply wnh .ll Cny &d Couly <br />orditurcG od Star. Laws Elriis ro &ildiie co.rnclioi. aid h4by drhori2. r.F.9tativ6 of lhir Cily ed Counly to 6ta upon lhc <br />ab.v.$oiioncd prop.ny for iBp.dion purpG6. <br />r-----T_----- <br />T <br />I