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APPROVALS DATE ID/SIG.COMMENTS
<br />I. as .wn rofthc ln,Fdy. or nry c.fkrrrc\ wnh wascl L\ rhcir $h conllEnsarion. willdo lfu w{lrk anl rh. {drm i\ mr
<br />inrcndcd or olTcrcd lor $lc (Sa ?o{4, Busircs lnd Eorcrsiotrs Cdlc: rtu cont.d.r's Licctrrc riw doer rer +Ply b dnowncr or
<br />rhcnnrEny who builds or inDmws rhc@n.,Jd who dms so.h MIl himscllor hcr$lfor tlrou8h his or hcr own.mlloyccs.
<br />rolidcd rhar soch impbvemms m nor inrcd.d or oftcn\] rd srL. l( ln'wcvcr. ltE huikliq or inwotftnr is oll wnhin onc )tr
<br />olon{'lcrion. thc Osrer Builler willhaE Ihc butrh. ol prcvnrg $arh.orsnc dil rei build or inrp vc rh.ImFry ror lh. NqFe oi
<br />-1.
<br />as owncr ofrh. Oqrny.0mcrclu\ivclycoDtrclins uirh liccrsc{ conrruchN ro.oinru.r rhc pm]cct (Scc. 70.14- BNncs
<br />x'nl t\)lis\irnCodc'IhcCoit,ctr'{Li.cnsctjsd.cstrordprlyro0nowncrofpropcrtywiohuildsorinDrcvcsrh.r.on.
<br />.nd who conrkk lor such projcch wirh r Conrncto(s) liccnq, pururnr ro rhc Cnnrrucrois l.iccn* I-ns)
<br />I n .x. rl, und.r S..r
<br />thl€ Ownerl
<br />rvoRl<a-i's' coMrltNrs Trd^i
<br />I}ECLIIA.IIAN
<br />I hcrcby rlIlfl. utrdcr p.Mllyolrrluryorc ollfic lollownr8 d(lanlions:
<br />I lDvc rxl will mnnrh r ccnilE0re of Co.scnt b Self lnsure for worksi Nmpcisarion, a. Fovidcd ror by Scctnnr 3'rOO ol rhc
<br />tjh.r Codc. for rhc pcf.nM collh. work for whichlh. p.rmil h hsucd.
<br />Xt hnv. trndwillnuinhin workcr'cnnpcns ion insurance. rs lcquiEd bys(ii(,n l7(x) orrhc Lahot C{dc. ror lhc pcrfonBncc of
<br />Nlysorkcn conrprn\ n,n insdrancc. di.r d B,li.yntrtr$crarc
<br />0l c@ Cozp.l/r/ r a- rq iBo I
<br />lcrnifyrh in (hc nerti)nuncc ofrhc *ork for *hich rhi\ p.nnir ir is\ucd. Inrlln.r cnrpliy any Ix son ir !n, muncr
<br />$dsk,bc.omsobjftrt,rhcworkcn'cotrrpctrsrr,otrhws.rcrlironrir.md{Srcdharil,shoul(lhccotrE\ur'j..rr,ih
<br />w rkc^ .oml( \d t'n pm$6n\ ol Sccrnr lTm of rhc Litsr Qxlc. l shall. n)n h*irh conDly u irh rk){ pmrisnnr
<br />wARNINC: l'iilurc lo ecurc rorkcn
<br />civil 6n.s up ur .nc hundrcd rhou$n
<br />Sc.li,r 1076 ol ltc L'htr(.ic. i crcsl
<br />onpc.srlk,n colc6se h unlo*tu|, did shdl \ubltr M cmploycr ro criminalFmlrts aid
<br />drto'. {!t^O.qx)'. in dd,lirtr,n r. rh. .u{ I lrnrrnsd'o1, damgcs r. n.n\idcd for rhr,^r,L"".lr-. , , /
<br />*"V,ub&,l(c,d_&ca <
<br />// LTCENSED C0NTR CIoR
<br />, ,/ I,IEOJBAIION
<br />hjTl n l'ccn{ uM.r nov'{,,n qlCrJrra a rcommn( rnp qrrr snrx'n 7n0i" olotrF.',n I
<br />md nry licen* is in tullforc and cITNl.
<br />I hcrhf rfit'n trnd.r Nfrhyoflrrry r
<br />ol {hc l]lri'r$ rnd lt.la\\n,ns Codc,
<br />c'?:1 C
<br />I K-
<br />SANIIAIJCIIIINIENpINCAGENCI
<br />I h.Bby amrn u.d.r Fnshyotp.rjury rhd thcE h a conerudion lcndine qcncy for tlE pcrforrotue ollhe *orr ror whih thk ncrmii i
<br />hslcd (S(. 3097. Civ. C.).
<br />AITLI!]ANLDECLAMIIO!
<br />I M)y fim undcr p.nal' y or pcijury om of lhc following d( lrat n,nsl
<br />Dcmoliin,n Pcr.irs Astrc(os Norifiori.tr Fedctul Rcgularioos (Tnh 10. Pan6)
<br />Rc!oiBd lJrrcr of Norirr@rion
<br />-l
<br />ccniylhd rhc itdcro I eau lol ions rcsudins asbcstosEmvll re nor arpliclhlc b rhis pDjccr
<br />Al .cn 'r) rhJr I h!\ c rc,d rh'\ hlnlrsr0n ui {,rdhd rhc lbovc inrornEr i(,n is codc.r I aere ro omply wilh ill Cn, and G'ury
<br />ordinarccs and Srarc La*r rlarins ro hlildins.onnoorion. and hcrcht nurhornc rnrcsrnhliv.s olthis Cily dnd Counl, n, cnlcr oB,n rh.
<br />rh,v. nrcrrnnrd |m,!cny f{tr ir\
<br />,\pDlirul or,\!rnl Si{tr h'rr ;, q-51B
<br />!P&ti
<br />al"lu e@ GdCL
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile SaIe ty /Low Voltage
<br />Fire Alarm / Dampers
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Solfit Rouoh
<br />Ceilinos (T-Bar Rouqh)
<br />Meter Release
<br />Rouoh I VrlP*tci\/
<br />Service I\Ieter ffnn"V fflAJd4tt ltt /
<br />nt\i t/Ffir*i 7K'
<br />Notes, Remarks, Etc. t w
<br />\, \, |[
<br />I
<br />ELECTRICAL-INSPECTOF RECORD
<br />Site-Work
<br />Communications Cable
<br />Translormers
<br />FINAL
<br />OWNER BUII,DER DELCARATION
<br />I h.aby arfinn und.r F.,hy or pcrjury rhnr I an ex.mpt rn n rh. ConlmcroN Licctrs l-aw tor rhc fouowins rcnvrn Isc..70ll.5
<br />Busi.c$ and Proi€ssion Codc): Any Ciry or Counly which rcquncs a pcmil ro 6n{tucr. altd, impovc, dcmolith or E|Et lny
<br />(tucru... prif b ns isuak!, al$ Equtd rh. appltMr ror sxch Fmrn b tb r ri8flcd $ak,mnl that hc or th. is liens.d ,uNMl
<br />lo rh. pmvisions oflhc Conlrnclrt Liccn*d L.w (Cnaplcr 9, CommtuinE wirh S.cri.n 7(xn or Division I ofthc Busincs and
<br />Porcsnrns Cdc) or rhar heor{hc i\cxrmpr rhcrcrronand rhcba\ir r(trrh.rllcgcd cknrlion Any violorionofssrto 70.1l5bynn,
<br />$Ilimd ror 0 p.rnir subj.ck rhc $plicanl ro a civil pc.rlry or nol mn lhan five hundrcd dollds ($50o)
<br />a,c:-1s^
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