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APPROVALS DATE ID/SIG.COMMENTS OWNI'R BUILDER DELCARATION
<br />I hcrcb, rmrn lndcr Fn,ky of p.rjury ltu I 0,D crc'llpt lmm lhc C.nrtucro6 Liccnk ljw for lhc fouo*iis rcasn (s...mll 5
<br />Bu\in.sr a.d Pr.Ls*rn Cde) Any Cny or Cou.ty *hkh rcquird r Fnnir ro consruct. lltcr. improw, dcm.lnh ot Ennr un),
<br />*trucrlrc, Drffro ils issuancc, ols,cqlircs rhcrorlicanr ad suchlf,irnil to filcasiSned \tdremnr rhxr hc o. sl'. ( liccn.c.l nuFu.nt
<br />ro rh. pmvhionq orrrE controcbls Liccnscd tiw (Chapt.,9- Conftncin8 wnh Scdion 7000 of Divhion I .l thc Busincs ond
<br />Pmfcsions Cod.) or th.rh.or shc h cxcryr lh€rcfron dlheb6nrorrh.dlcE.dcrcmntion.Anyvi{,lnri.nofsdion}0ll5b}rny
<br />rltlicant lb. a pcnnit subjdsrhe aprlicanr 16 acivillcnalryornot trrclhan iive hundrcd dolla^ {St00).
<br />-1.
<br />N owner or rlr ptupcdy. or my cnDloyces with *aacs as lhcir {nc co'nFns{io.. *'ill do rhe w.rt oxl rtr sMm s mr
<br />intnd.d orolTclcd ftr elc (56 ?()14. Busincs rnd Ptulcssiotrs Codc Thc Conrracrois Li.cnsc Lrq does not onPJy ro 3.own$of
<br />rhc!tuFny who trildsor itrDrowr thcEn. ri who d*s ikh wort hnssclior h.rslfo. ihough hh o! hcr owncmPlorcct.
<br />Drolidcd rhtrr such inPlokmnh nrc nor inlcMcd or oltcrcd t$ slc li lswcvd. rhc huildi"-! or t'll'rckcm h sold wnhir nc ,cr
<br />ol co plclion. llE Ovmr ltliHs will h,h rh. rontcn or pmvin8 rhar tr or shc dn d buiu or itrlmrc $c pmpcny tor rh. trq$e of
<br />l. is osrE ol'rhc pRrpcny, r'n crlxsivcly c.nrtclir8 *ir h liccn\ei contactr k, .onsru.r rlE tmj€l (Ss 7O4 r' Bu.in.$
<br />md lbfL\sion Codc rhcConlrocroas l-i.cnsc l-!* d.cr noi aptlyb 0.ouncr.lnroPcnr*h. buildi or iml'lovcs lhcr.on.
<br />lnd who conrracrslnr \r.hpn*cr\ wirh r conrflrtr(s) licc.{d Pursuanr h rh. conarrors Ltcnsc Lr\'l
<br />I )r cx.'nfr trnd.r Sr.r
<br />Dole: Orner:
<br />WORt(En.S' COMPT'NSATIoN
<br />DEII.AIAIIgN
<br />I h.rcby a0nmundcr pcnaltyofp.rjuryom ot rh. rollowing d(lamtions
<br />Ihav.e *ill minrain ! Ccnirrarc ot c(nMnt
<br />'o
<br />s.lr-l trrurc rbr workcn conD.nsarnr, .s l,ovidcd for h, Sdrn,n ]70o ol rhc
<br />l,l$r codc. for lhc pc{omuncc of I hc work r(r wh i.h rhc |).rmil is issuci.
<br />I h^r LMNillmn air s.rkcrs .onpenslrion in\nrrn.c. as rrqutM by Sccri{'n .17(D of I hc trtxn G)dc. for rh. Pcrtorroncd ot
<br />rhd sork ntrwhth lhisrcrnril is hsuc\I. Mr*orkcrs.. rt.nrrfn ir]sur..cccaric.lndPolicynufrhfurc
<br />;d If)N,L^{rl 3no-?.q
<br />I ccnilythor inthc pcrforromc ofrh. work for shi.hrhis Pctrnil is hsuql- I shtllnor cnrPloyanyPcron inDnym.nn.r
<br />s !s r.' bccoft slbi*i h rhc workc^' conDcns.l ion laNrofcrliturnir, nM.8nc lh.r ift should hecoft subii ro Il'.
<br />*ortc6 mmpensrrio. p$visi,ns ofScdnrn 3?(x)olrhc lilir Gxk.l sh.ll.lonhrith.omply wirh rho{ ptuvthns
<br />W RNING lj(ilurc ro su.. $rkc*' .omr.nsdion covcnSc is unlNful. md sh,ll subicr an cnDloytr b onni.d lf,naltis and
<br />civil lincs u!) lo orc hudrcd rhuuia.d dollnt ($100.fiIJ). in oddirn,n b rh. co{ ofconrlcnsrlion. dahucs rs ptovidcd ntr $c
<br />S..r D .ro7a ol ih.l rhr
<br />-nAI 17 '&isx,:'^"'
<br />I hcEhyafllrnlndcr p.nalry o I pc.jury Ih.l I a'n liensd uodcr pn,liri.norCh0flcr 9 (comflstuin8 enh sccr6. 7uO0) ofDivhion.l
<br />ol rhc Busircss snd Prurcssions codc, orn my liccnse n in tullfore d cffftr.
<br />\rgoqtqs,
<br />NAY
<br />C,ONIIAI]SIONIENDIIC.IAIN1;I
<br />I hcrby afirnundc! IE.ahroapcrjury rhnr thft h a snsrtrli,tr lcndins ascry t r lhc Felotn:amc ollhc wo litr uhi.h rhh !.rmil is
<br />hsued (S.. 1097. Civ. C.).
<br />AffLICANLDECIAf,AIIQN
<br />I trNbr.finm undcr pcnllty otpedurydnc otlhc following ddlomlions:
<br />Dem,liion Pfimirq Ash.nos Nolificltion r{dcralRcElLlions (Tnh 40. Pd6)
<br />-Rcq!ired
<br />Lcrrcr of Norificdi0'
<br />I ccrlili lhol ihc fcdcral rcslhrions EsardinP asbcst s Enrval nrc ml a0tli.ahk k, rhir Pmj.tl.
<br />-lccnilylh.r
<br />I hsvc r..d rhisamli.lliona sl!t.lhar Ihc atnv. intomrion is corol I!Ealoo mplt s hrllCiltnnd Counrt
<br />Ciry.nd Counly 1,, rnrr t|i)nrltodinlNcs o Srrrcljw\ toldrinAto buildinS.on(ncli,,n- unl hcnht
<br />nlF\. mtrri l nrcprny lor t,.ltrrriotr pur|x HAY n V mlfi
<br />,1DplimDl or Atetrl Signalu(
<br />*n'/rt,.x-
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilinqs (T-Bar Rouoh)
<br />It/eter Release
<br />Rouqh u.o(rt Q dultl .{,uq ol
<br />Service lvleter-FINAL K'?{Ll/t e 9D 6s
<br />Notes, Remarks, Etc
<br />ELECTRICAL.INSPECTOH RECORD
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