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OWNER BUILDER DELCARATION
<br />I hcEby amr ondcr pcnllry ol pcrjuly rhlr I am cxcnDl riom lhc Co,rrrclon l-iccn{c L!* {or lhe follo*ins rcr{i (Se70.ll5
<br />Businc* Md Pnrfcsion Codc)r Any Ciry or {trunry ehtuh rcqrtcs s lltrn b ..nnrud. dr.., improvc. d.molish or Epuir 3ny
<br />srru.lurc. prior h ns kuoncc, 8ho Eiutcs th€ 0p/icd for iu.h lrrnrit h f,c r si8trcd satm th hc or shc is liccnscd purs0nt
<br />h rhc pmvisions ofth. C.nlEclols Li.enkd bw (Chnflcr 9. Connr..ing *irh S.c(i.n 7ffD ol Divisiotr 3 ofrtu Busiocss rnd
<br />Profcssions Codc) or lhat [corshc iscxcmpl lhcrcarom and rhc bdsn ln rhc rllc8ed cxc'nflion. Any violathn ol Sdio! 70.] 1.5 h, lny
<br />,npli.rnr ror a Frnrir \rbFcBrh. lptli.ad er s civil Dcnalty ot nor n,c rh fiv. hundrsl d.llan ($500)
<br />L r\osn.rofrhc pnDdt. r r.rchNiv(lr(onkrring sirh lircn\.n.otrtxcktr\ ti coin'a.r rr In,l..r (Scc 7(N,1. Bustrcrs
<br />d.d llnlissir Cdnc lhc (onkrct.r's l-iccnr l-& (bcs nol rprlv k, ro\ncrolnropcny$ho htritlsor nnprcvc\rhrrrotr.
<br />dtrd who ro nrrr\lnrsurhfn'1..($irhaCoikrckir)lit's. puftuxtrrhrhc (i rr(kr'\ l-i.cn\c l-rq).
<br />I rmcic lI, ri,ldr Sc.rio
<br />lrof,Klif,Stro lfrNsa.Iloa
<br />DICIdAAIION
<br />I h&.by rlarnund.r Fhalry otp.rjury onc orihd folk,wing {lcctmri{rn\:
<br />I htrvc el s ill tuitrrrin , C0 riiicrrc of Con\cnr r, SclflNurc itr workcn .onrp.n\rii,,n. r\ pR,vid.d r.r b!Sc.rhn lTUlotrh.
<br />I trtx, ( odc. Inr rh. Fnbrroncc ., rhc so& ntr Nhich rhc p..nrir ir isnNj
<br />I hrvc rid Rillirinrrnr sorkcra.otrrfnsrrioi nxurrmc. r\ rrqrnrJ h!S.dtrnr 17(N)ofrhc lnh.r Cidc. hrrhc pcni,nrr.col
<br />rhc work lnrwhirhrhr\ p.nnir i\ rsucd. My$orkcrs conpcnsrri,r nNnrni(cudcr trllx)li.y iu $cr rc
<br />I ccdify rhrl in thc ncrfofluncc {,frh. Nork fttr shl(h rhi\ Il.lnil is issu.J. I \hrll nor cmpk,y r'ry p.(on in rny nrtrkr
<br />$ .s lo b..om suhtt{' ro
<br />'hc
<br />wo es .onrr.sarb. laws ol CrUturnir, rtrd tr!^-c rlu il l dsuld bc.o'rc subjccr lo lhc
<br />wortcn.onlp.nerionprovsion!ofSLrtiotrST00ofrh.LahtrCodc.lrhrll.n)dh$irhcoardywirhrho{pmvhions
<br />WARNINCT ljrilurc b Burc wr[en comNnsalion corchBc r\ unl0*tul. rnn shnll suhjccr ar cnrpl.yer r. criminrllrnrht\ ald
<br />civil nnc\ !p ro onc hundrcd rholsand dollln lsllD.()(x)). in itldirio ro rhc coslolconrpcnsari.n, d!roEc\ Ds providcd nn rh.
<br />Scdion 1076ofrhc lihnCde. inrere(rod alonry\ lc.{
<br />1/ /21 I ( o,,,,-",,
<br />DECI,ANAIO!
<br />I hcEht nmrmxndc. r.n.l'yorpcrjuryrhar l.n li(6$d undcr p(,virion orchapt$ 9 (oNErcin8 *ith Salion ?fixr) oiDivnion 3
<br />or rhc Busim$and PretcsinrBC.dc, ard dy liccnse n in tullforcc md eltel
<br />a/tzltr ,;q
<br />CONEIf,I&U!.INIEIDING.AGENII
<br />I hcrcby lffirm u.dcr !.ntrlly of pciury ll'al lhcE h a consldclion lcndin8 {gcncy for thc pc ornEe ollhe work for shich lhis Fnrir ii
<br />issucd(Scc :1097.Civ C).
<br />AITUIANIDECI.Af,AUI.N
<br />I h.r.5y aflim undcr Fnalr, of pcrju!, ore of rh. followins dehrul ions
<br />Dc,mhion PcnnirrAstEstos Norificorion F.dd,l Rc8uldions (Tirl. 41,, Pan6)
<br />_Rcqutcd lrricr of Ndifi calion
<br />I(nilyrhrr rlr lidcrxlrceu[rio \rc!]rdi'rgn\h.no\r.'no\rlrrcnorrtfl'cnhIt,rtnffl)jrd
<br />-lccnilyrhd
<br />I h!!c.can rtulprlicrrionanlnlrcih0r rhctrtntt nrLrnrrion hcorc.t I rlre b c.nDly sirh all Ciry a.d cortrr,
<br />ahovc nrtrriolL.d I)fuN y tur ir$""''/\""'*'po ltzlttADplic{rl fi A*cnl Si*nnlum.
<br />APPROVALS DATE ID/SIG,COMMENTS
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monumenl)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Bu ild ing
<br />Under Slab / Floor
<br />Bondin g/Grounding/UFER
<br />Transformers
<br />Torqueinq
<br />Air Conditioners
<br />Roof To p Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilin gs (Hard & Solf it Rouqh
<br />Ceilings (T-Bar Rough)
<br />Meter Release
<br />Rough
<br />Service lvleler
<br />FINAL lo /ta /*S[ Efr
<br />Notes Remarks
<br />AL4
<br />e\..^
<br />^5,;
<br />ELECTRICAL.INSPECTOR RECORD
<br />-1.osownsoflhclm,tny.ormycmtbyNspirhwa8c(trsrhcn$h.!mF{bn,silldortEwoll({nlh.(ulurci\flnim.ndcn or ofitrcd nr sb (Ss 7044. Busirc\r an{l Prolcssions Cq,c: ltc Conrraclorr Licen* hv des nol amly ro L.o{ncr.r
<br />Lr DmFny who boilds or tuipn)r3 rh.mn. and sho dcs skh uorl him\clfor h.s.lfor ih$uEh hh o. h.r ovn cmployccs.
<br />pn,vidcd rhrr.kh i pnrtmn* rc mr imcndcl orcrcd fin srlc lli ho$rls, rhc hui|ing or n{nokn* ksU*irhin.ft}rJ,
<br />or comphrion. lhc (rncr Buildcr *ill tut rh€ t u cnolpmvinslhat tE or shc did nor buiu o, impmE lhe rnFny ld rhe pxq.{ or
<br />Lrndo . Addrc$
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<br />Sub-Panels
<br />EIC.
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