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APPHOVALS DATE ID/SIG.COMMENTS OWNAR AUILDER DELCARATION
<br />I hcrchy aflnnr undcr rnohy ol Frjury thol I m cx.mpt fo'n lhc Conlrlclon Licenrc Liw fo! lhc fohwins rcasoi (scc.7oll 5
<br />Businc$ ad Prolcsion Codc): Any Cily or County which rcquncs r pcmil to con(ruc|, altcr. ihp.orc. d.nolish or rFlr any
<br />srdct!,c, prior to irs hsoarc. aho Equtes rhclppli:ant l'or such lErmir ro filcasisned srarcft.r rhlr hcorrle is li.cn(n pursmr
<br />to thc ptuvi\k'ns ol lhc Cont,cior's Li.ens.'l bw (Ch,pld 9. Co,Mcftin! wilh Scction 70m oi Divtion 3 ofthc Businc$ ond
<br />PD|'csionsCodc)orlhartEorsicircxc'ry,rlhcrciofllndfichisnnxrh.allc8cd€xcnu,rion.AtryviolarionofS*rb.70:ll5brdny
<br />imlican' f.r , p.mn suhirls rhc apdiclnr to , civil !.nrlry or mr ,mrc rhrn fivc hundrcd dollds (3500)
<br />l.!\ o*rcrofrhcpmpcnr,ordychplortcssirhwlgcsrsrhcir$]cconp.n\arion.willdorh.*od{ Irh.sttrnrcsnol
<br />iird t.1] orollc.cd forslc tS( 7O,lJ. Busincs and Profcs rns Cod.: Thc G,nr,crtr \ l-i..nr L{w docs nor rp/y ro an oqrcr ol
<br />rhcfmlEny who build\ or rl0a)rcs rh.N)n. ond whd do.s skh wurk hnnlclf.r hcr$lfor rhmuAh hls.r hcr own cnrployccs.
<br />Pn)vidcJ th r so.h nntR,lemnrs m nor i, .ndcrl d ofl'.El for elc lt h)wcrr, rl.. h ikins or irrmwmnr is v,ld wirhi'r , rt F.tr
<br />of$nl,hri,n. ih. O$,ncr Buil4cr will hnvc rhc l,lrdcn of provilg rhd hc or shc did nor htriid or in{nxr rhc F,pcny for rhc l,lrPe of
<br />-1.
<br />* owfl( or rhj lrcpcrly, amcxclusivclyconlra.rinS snh li.cn\cd .ontract,u h .onstfl.l lh. pm]ccl lsec.'7(144. gusincs
<br />rnn Pn,fc$hn Codc ThcConracrois t,iccnrc Llwdocs not anply b !n oNnc. or pn,Eny eho brildsor impn,vcsrhcrcon.
<br />and who.omr^-hfor\u.hpml..tswirhrcoNmcr,(oliccn\cd,,unurnrrorh.contactolsLtcorb*)
<br />-l
<br />amcxempr undcr S.ctio
<br />lroaf,lEstl;oMfEAsallo!
<br />D&CI,AMIIAts
<br />I h.rcby alfirmundcr Fnlhy of pcrjury orc of lhe tollo*in8 &dmlions:
<br />-l
<br />hlw n will Mitrllin a CeniaEate of Consnl to Sclf.lnsurc lor wolkss cohpcnsriofl. !s lmvidcd for b, Sccrion l70o ot rhc
<br />tjhor Cod€, aor lh. pnroflM. ol llE wolk for whih dE Fmir ir issucd.
<br />-l
<br />hlvc snd willmrinl.in wo cn compcnsatiofl insuEmc, as r.aliEn by Scct ion l?00 of lh. kbor Codc. lor th. Frfm.cc of
<br />I conr.ns.rion insumrcr clricr ud poli.y nu'nhcr &
<br />(<rublf-otSao?o \.\.\q
<br />I crnily rhrr iir lhc perl]tnumc {)idr sork ntr *hi.h thn t--nnir k i\\ucd. I \hrll nor .nrpby an! r.Aon i" rtry nutrnd
<br />v, a\k,h-om subj.cr brh. woft(i c.nrrrnsrr i(,n hw\ofcrlif(r niddlNrhdif l{"()uld h.c.rN {rhjc.r ro rhc
<br />sorkc.ump.i\ariuipfl,vsnrNofS(ti:l?0OofrhcLahrCodc.l\hrll.li)dhqirh.omDly*irhrhoscp'.visi,nr
<br />IVARNIN(;: Frilurc t, {curc r1trltr^ .o'nnctr\ rnm covrrrtc i\ unh{irl. nnd \hrll \objrc r lo fliniral pcutics and
<br />h onc hundrcd rhoxsrnd dolltrs (sloo.fiD), in dirion h rhc co{
<br />uii"ii-iutu-
<br />I h.eht lnrd u idf r,.nrkt of Frjury rhar I inlk.\.Jund.rptuvinonolChrprc.'r(.onnNfrin8silhSc.lin,?(XX))olDivisi(rrl
<br />of rhc Busirc\srnd l'tu1[!\6nsCoJc. nd ry |i...\c i\ ii fulltu(c M crf.cr
<br />g \o?^€\V
<br />taq,tsrr. .,ItAp+t ]Jllt
<br />rolslBrJcr.l0tlrlDMi-&uDtic.r
<br />lltrrhynlfiiinund.rFnrlryofp.ijuiyrhmrh.oisac.n{flcri,nL.diren8ci.!turhcFrloarrncc.irhcw.rklbrrlri.hrhi\pcnniri\
<br />ksucd(Scc :lO97.Civ.C.).
<br />tx.dci Nam:
<br />-
<br />A.E}IICANIDII;ITIMII!}!
<br />I tst, atfim undcr ll.nslt, of pcrjury o.c.rrhc firldvin-s dsl!,arii,nr
<br />Dcmlition Pcrmik-Ash.stos NoIific.rion Fcdlrol Rcgul ions (Tirlc 40, Pfi 6)
<br />-Rcquircd
<br />r.lrcr of ttoliticalion
<br />-l.cnilyrhar
<br />r hc ,cdcal rcglL! ions re8arding ,sbe{os rcmovd !r nor spplicablc b rhi\ !r.jc.r.
<br />deni! rhnr I hlvc rc.d rhn lppli.orio, and srarc Ihar ihc atnvc inlormrion is.orNr I !!,Eroondyairh,llciryond counly
<br />odiMtrccs rnd Srllc L,ss rcbring ro huiklinB consrrucrnrn. and hcrcby trurhorizc 'frhhCir!r d Cotrrlyro.trlcr lll)or rhc
<br />rhovc 'rctrrnnrd |fi,l.nyLr nsNdn rNr
<br />Applira l or Agrnl Sian lufr:
<br />.<-),l't,LI A,:*,
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />$pas, Pool, Fountains
<br />Signs (monument)
<br />Lile Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Translormers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Solfit Rouoh
<br />Ceilings (T-Bar Rouqh)
<br />Ivleter Release
<br />Rough *z /k , Ten 27pg€
<br />Service lt/leter
<br />FINAL [,/@/k ;D b-D
<br />Notes, Remarks, Etc.
<br />ELECTRICAL-INSPECTOR RECORD
<br />W,N l trta
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