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ID/SIG.COMMENTS OWNER BUILDER DELCARATIoN
<br />I hcRby ,lfirn xndd !.nrlry .f I,crrury rhar I 0m crcmfl tisrn rhc Conlraclon Licenr ljw fo. rhc f.lhsinE rcasn i Sc. 70l l .5
<br />AusiDc$ 0tr,1 Profcssion Codc) Any Cily or County whth Equne\ a ncnnir ro connru( alrcr. inpmec, dcnrlish or rcl)an any
<br />{tu.rurc. pri.r b irs
<br />^su@..
<br />al$ rcquirci rh. iriplicdnr ftr \&h lrrmn rn filc u siSncd {arctrht rhd hc or slE is lien$d puN.nr
<br />lo lhc,novisions oftlE Contraclols Li.enEd Llo (Chrplcr 9. Conrnrcncins wirh sc.rn,n 7ux) ol Divnion 3 of lhc Bu\incs rtrd
<br />Pmtsn,ns Codc)orthal hcor\hc ircxcmpt lhcrcftorufrllhc hasn nnrhc,lfuCcd cxcnrrliotr. AnyviolationotSccrionTo.ll.5hydn,
<br />ap!'liconr f o pcmrir subjcch Ihc lpnli.a r. acivill}€n!h,olnor' trc rhu fivc hnndrcd dollrs ($500).
<br />-1.
<br />ns owmr of rhc l,o|rny. o ny cmployes with $,acr rs rhcn q,h orpcn{ll ion- will do lhc wtnk urd IrE itu'm n nor
<br />inrc,rlcn or oficrcd for sk (ss.?tx4. Ausiness and Pnar$htr\ Codc: Tbe C.nkD.'{, s Lkcn* tjw des not rpdy ro ao owncr of
<br />rhc pnlrdy wh) britis or inprovs lh.Nn, arld *h. dGsuhwo* hrmscll or hcFellorrhmughfiisorhcrosicnfloycc{.
<br />polidcd Ihar uch iDpmEmnh m rer inlcod{d or ollcrcd ior slc. lt lx'sser. rtE trilding or iq)x,rc'tunr i{ btl *irhin onc }c0.
<br />oacotr{,lcrion. rhc Owmr 0uit-Li willhlw rlE hurilcn ol pmvins rh{ h. o. snc dil nor t uild o, i.lpnrc rhc flDrdy rd rhc ru{b\c or
<br />I. !sorftrofrhc pmpcnt. shcrclu\ivclv.onrn ring *irh lic.n\cd c.nt:BloF to con(rucl lhc nmjccr lS( 7(114. Bt.i"cs
<br />ad Pn,li:rio. Codc'Thc Conracrols l-iccDsc tjw docs nol arDly k) s. owncr orprcpcny who buildr or nnpr.vcs lhercon.
<br />and who conhcrs ror \uch ltr'&.r Rilh r contac(,ll) lic.n\.d pursun l0 th. Conlrldol s Liccns ljw )
<br />I rtr,.r.n,nr un,lcr S.cri(
<br />Dlle O*oE:
<br />wonxr'*s' Ir)[rprrrii,rrlo:r
<br />DECLAAA.IIA!
<br />I hercbt aflnn undcr pcn yolr.rrury orc ofrh. f.ll.wint dc.ldarioncl
<br />_l hrve and willminlaio a C€nili.arc or Con*hr lo Srlt ln\xE for sortcrc' comFcnsrlion. .s trovidcd for bySedion:1700 orrhc
<br />L.hor Ccdc. to'rlrcFalommc ntlhc rcrt lhr trhthlhc ponrn s F.urd
<br />Llhiec rtul $,ll'tuinra'n {orkc^'corn .nq.r'.n nur,kc. f,! i.quied by Sdion l?{x, oirhc hbor C.dc.,or rhc pcrronh,ftc or
<br />Myqorksr Ll,np.ns otr irNur0n.cc0tricr iDdpolicy (o(-Fr'
<br />I
<br />t Ar4 /tot Jll r.n).,
<br />-lccniiythili"rhcpcrloi,mnccoilhcworkt)r+hichll,isrcrn,ir
<br />i\ is\ucd. I \lrll tror c t ('!a y Pcron in ony nrinocr
<br />$ rs l(, h.onr suhj$r ro lhc sorkcn.omnctrsrhnn l0w( ofCrlik'nria. o r8rcc rtur ifIshould tEcomo suhrcd hrhc
<br />$or*c^.ompctrsilionpmvtionsotScclion.l'r0oolrheL.tErCode.lsh!11-ionhwirhcomplywirhtho*pnJviids
<br />WARNINC: l(ihtrc to rcurc sortcr\
<br />civil finc\ up lo otrc hundrcd rhoussnd
<br />Sccri :l(,76.frhc ltrhtr Culc. inidto{
<br />lotr,txtr\:(i,n, N.n!c n trn[$l,l l. ,nd shall subjor an cnl,loycr ro flinr
<br />rhr.on of.on[.n$rion. d{rm8cs rr
<br />fd,'t Gr*s/
<br />UI!LAB{I,!A}
<br />I hcrchy lnirnr uMcr rn.hyolFljury lnd I in lianan u.dcr pmvniotr of Chaprs 9 (qmmncing eirh Sdcrion 7000) orDivnidr l
<br />of rh. Brsitu*and Pn
<br />'fcssidn
<br />s Cod., il nry li..n\c a nr fxll foN dd cficct
<br />{
<br />3 ,1
<br />I hdrcb rflntr,utr{lcr p.nrlryor rjuryrhrr
<br />t$cd (Scc .10e7. Civ. C )
<br />Lcndeis Adrlrcss:
<br />-
<br />APIIICANfDECLIIXAII0N
<br />Illnhy0mmund rcnrlry.l'pcrjuryoncolrhct,hrwinsdcclirrlionr
<br />t)cm'lirio Pcrnrirs.Ash.sos Noliii..riotr ftdcral RclUhrlnrs (Tirlc40. FurrG)
<br />Rcquircd t-crr.rol Nohll.di(nr
<br />IccnifyrhrrIhn!rrerdrhNrrnli.ariondrdqtar.rhrrrhcrh,vritrfoiurionn.or.cllarrccloconrply$ilhollCirradCortrry
<br />ordi'r.cc\ d Si.rc liw\rcldi .,"y",ivcs of lhh Ciry Md Cornry ll, crrcr ug,n dk
<br />Jtxnc DEtrrilnr{l f'opcny nr
<br />'.," 2t1 ( /'Ardp *4L.€7
<br />Site-Work
<br />Under ground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Founlains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)IPIIL fl 't rtp ^t\t1/.,Ltf9'il
<br />Ceilinqs (Hard & Solfit Rouoh 0\)-N
<br />Ceilinqs (T-Bar Rouoh)12't 7"ty x"w10
<br />Meter Release
<br />Rouqh
<br />Service lvleler
<br />FINAL .nY"fC4,z-a)
<br />Notes, Remarks, Etc ra
<br />ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE
<br />_l ccnilyrharrhc fc&r0l rcgulat ions rc! ning Nhcsros rcnmvrl trrc ioi atdicihlc rothi\ [orccl
<br />l/tnln'n I
<br />I
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