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APPROVALS ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I h.rcby rfltrr undcr pcnllry or lclury rh l im cxcmfl fi,d rhc conlr&kni Liccnlc lrw for rlr n]l!'winP rc.$n (Scu?oll5
<br />auurc$ .ntj Plrt*tr)n C(iic): ny Ciry or Counry *hich rcquircs . IEmir k, consrnr.r. .lrci imrr,!c. Jcnnnh r tuFn riv
<br />nru.furc. prrn io iB $uancc, lho ,.quiEs rhc appli.dr n, such llcmir t, lil. a ngncd nd.tunr rhar lt or she ir lt.nsd lllislanl
<br />b rhc ptuvsions oi rh. Coordcttr's Lcnsqi Low (Ch2pier 9 commn in3 wirh S..rion ?0Oo or DivNon I ofrhc nusitus &d
<br />Pn,tlsbn\ Co'lc) or rhd hcorshc il c\chor rturlidm and lhc$ash li)trhc rlldgcd cxcnrPlion Anyvn dbnolsccrioiT0ll5hvanv
<br />appli.anr ror a p.rmir subjcch ltu attlicantioaciviltcnahyofo.rmrclhMlivcntn'trt{ldollds(5500
<br />l. rs owtrc! ol rhd l,n)trdy. or nry cmlhF.\ ,nh *ag8 Ls rhcr. snc dnnncn\d Dn. wil nd rlE work d,rJ lh. (Brh \ ndr
<br />txcntcd oroll.r.d tur srle (Scc7(14,1. Blrftss.nd PRntsions Co.l. lh.Citnrracktr\l,ir.n\cLawlocsnorrtplybatroqncrol
<br />rh. BJtf,dy who hlrldr$ in{'otr rhcr.!n, d! who dEs $ch w,* himscll ot hcrellor rhi(nr3h his or hcr own cmFlovcc\.
<br />povidcd rhd nrh innn)vcm.6 r. Rn i,r.ndcd .r.tlN.l lat eh ll. lokv.i rhc huil'ltrr! or mllrtuvcntni s $l'l wihm onc ){:ar
<br />.l uomp|rtr)n. rh. Own.r B!tucr will hlt rhc hrrdd dfpruvm! th.l hc or \h. Jd n.r ttrilj or Fpn)rt rhc lnrFrlv li)r rlr PuqDs'f
<br />L isowncroirhc ll)p.dy, !Nciclunvclyconkacriry wi(h ltcn\c!.ontrr,s kJ.on(r!cr rlE pol.d (sLt. ,7O{4, Buinclt
<br />a Pnnar\rr C\dc: l hc Contr.fu \ l-iccnse Ldw d,Es .or rplly b rn.*ncr oi lropc yDh(ihurl'.ls.rin{rov.srhcr'on.
<br />lnd Bio ronkacc for ruch pmrcct wirh a Conkn bn O lrccnscd pu^urr (' rhc O[rrtttr s l-irn\c Law)
<br />I !'!.\c'n!r unJcr S.cr a & PC n)rrhsrci$n.
<br />Ila85E8[COlItENlArlON
<br />DECLAR-ATION
<br />I hcrcby alftfr und.r pcnalry oI pcrj!ry onc oi$c lollowins dccleaiions:
<br />thalc{,villm' rin r Ccniliqrc orco.snl lo Scl[lnslrc lor soi*cs' ompens ifi.as provid.d lor $v S(rrn :l?{x) or rh'
<br />tibor Co{c, nr lhe p.rfo@c oi lhc worl lor whnh rhc p€mit is Gsue'i
<br />-l
<br />hale ed wiu ntintrin wotlc^' .oml.marion rsummc, .s ,cquircJ bv Selirn J'700 ol th. bhot Codc for rh' P'rlirm'n@ ot
<br />rhc *ork tur whrh thG pcmir is Bsdl. M, workcs dmpe nsation iBurlM sier aol Plicy .umb$ rc:
<br />Poli.y Nunhcr:-ExPncs:
<br />-I ecditu rhai in rh. lEI lnrmn . ol rh. work nt which rht pcrmi '\ i\{'cd. I {ulln.r Mrlndv anv ix.vrn in rnv nrnNr
<br />i, N n) h..uN utjcd t,lhc sotkcs.ompensarn,n Lwsofcdlilnnrin. an,l x!tuc th iil \houll L.onr Nrbicd n'r^(
<br />*orkctr conrp.nqtonlnrvnions oiScrrion:lTlDol rhc Dbor Cixlc.lndl nnlheirh.onrlly wirhrhok Pr)viri.ns.
<br />IVARNING trihrc b {curc wo*cn ormp.ntrbn covcixge s unlawtul. dd shall s'h,ccr rn.lnln,vcr lo cnninal lEroltis M'l
<br />cNn ires up ro onc hundmd lhousand lollan (Sl{x),(x)o), r addil'on 6 rh. co( ot comp.nsr n am!8es ar pr]vntd tnr rh'
<br />sc.tion]016 ol rhc lltrrcode, tnlcrc( ao'l ody sLcs
<br />loDlimnl:-
<br />LICENSED CONARACTORpEqldBlllloN
<br />I h.Eby a,lom undcr JEnlllyotpcrjury rhal I am licensd unJfi prevnion olChaflo9 (4mmcroins wnh S.dirn 70@) otDiviion l
<br />of rhc Bxsifts and Pmhssn,trs C.d., and my lsense n in fiill t)td ,il c,lt.l.
<br />-LNnrc
<br />Numhcr:
<br />$I}IEIEqCUONTENpEIiICENCr
<br />I htrhy dftnn undcr lEnall, or !.rjury rhal rh.a h a @nddcrion Ic lir8 4cmy tur lhc lErtanmn.c or rhc mrk lor whth rhc Isnir Ll
<br />issuen iS.r. .1097, Civ. C.)
<br />ATPLI('ANT I'E('LARATION
<br />I lERrry rltim u ndcr aanalry olr.riury dnc olihc 61!,sin8 dcclrarns:
<br />llcm)lion PcinneAshc(os Noriir ion Fcdclal Re3ulations lTnlc 40, P!n6)
<br />Rcqun.d hllcrol Notiidrtr t
<br />-l
<br />c.niti rhd rhc l.{.ral tcrubl ions c8ddi.s rcb.nos rcnDvrlm not a$licnhlc nr rlrt tniel
<br />l ocnili rhar I hav. r..d rhn apolicll n,n d {.rc lh.l rhc .h'v. inromEron s comd I r8N lo .omllv wirh ,ll Cilv lnd Coun(v
<br />ordinands xrd Sr,r.l2ws Eblins ro building constnr.rbn. ad i.rby authorizc Errcrntariv.s dlthn Ci!v lnn counrvlo cnrcr ulon lh'
<br />$ovc nrcnriorcd ptur.dy ror i.sp.dnr tx{rxcr.
<br />,\ppli.anl or,\renlSiflnrlu
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Siqns (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER
<br />Transformers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Sollit Rouqh
<br />Ceilinqs (T-Bar Rouqh)
<br />Meter Release
<br />/,^\
<br />Rouqh ,-21.10t *"Wnd
<br />Service Meter t-(
<br />FINAL L'lS-},|V.A
<br />Notes Remarks EtC
<br />ELECTRICAL-INSPECTOB RECORD
<br />DATE
<br />LctrJ1 . A'lJr*
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