|
APPROVALS DATE ID/SIG.COMMENTS OWNER BUILT'ER DELCARAI'ION
<br />I h.eb, anirr u.dfi ,cnally of lc4ury lhat I dD crcmpl lion rh. ConrracroF l-k.nsc Lrw r{tr $c lollowing rcaen (SN.?0.11.5
<br />Busincss and Prcac$iotr Codc) An, Ciry or Counly which rcqlircs ! ll$mil ro .oislrucr, nltcr. imptovc. d.mlhh ot tpan any
<br />ntudrE. prior ro ir isruskd, ds r0itun6 rhc aptli.nd tJr qu.h pcrnnl ro filc r si8mn stlrcnrnl rhsr he or shc h li.en$d pu*udr
<br />lo thc rovhions ofltE Conlra.lols l,iccnsed tr* (Chlpler 9. Cohm.ncins {irh sccrion 700iJ of Divhk,n 3 of lhc Bosinc$ and
<br />Pefcssionr Gdc) or thar rs or shd h.xcnrr lh.rcrro,n and rhc basis i{n rhc ullcsed cxcuDrion. An, violuii.n ors.clhn 7011.5 $y any
<br />ippli.ad for a pcmit subjcch rhc !tpli.anl ro acivilpcnallyornor mft rhan iiv. hundrddollarc (SsUJ).
<br />-l-
<br />ar owncr oa rfic pop(n!. or my cnpl.ys\ snh wa!c\ as rhct s,l. .onwn$tion. sill do rhe *o* lnd rh. {nfm n rcr
<br />idcndcd oroilcrcdforsrlc(S(Ttr44.Busi.csmdPofcsio.sCodcThcConhcroisl.iccnscLlwd..snolaPpllloan *ncrol
<br />rhc tolrny sls hoil& or iqx,rd rltmn, and who dd skh $oa hinsclf or h. cll.r lhrough his or hcr ow. cnfloyc.s.
<br />pr.vidcd rhar su.h nnprornEnts arc ml intcndcd orollcrci lirrsule.Ill hoscrci rhc buildir8 or nworcmnl Gsold *irhin.nc Fr
<br />.r.otr\,Lrir. rhc o*rcr Build.r will hirc lhc tonlcn of rrovin8 lhd hc or shc did nol t[ild or nryrnlc rhe pmFdy for lrr puqDc of
<br />l. rsowmrolrh. protcny. nrcxclusivclycontadins sirh liccn*d conr racr.6 h .o nsr d.r rh. lrojd (Sc. ?044.11u\im\\
<br />lnil PmaLssnn Codc Thc Conlncroi s l-iccosc l-r* {l€s N srrDlr b an own$ or [op. y sho builds or i',IrJv.. rhcrcon.
<br />rnd who $nrB.B fd \xch polc.ts wirh a contrncbn 0 lftnscd onnunt lortc contu.tn\ l-k.trs. hw).
<br />4 ed4=
<br />I}EII,ASAIION
<br />I hcrcby.fitmundcr pcnalryotpe{uyonc of rhc folk,$ins dcchrarions:
<br />-lhlvcandwillnminroinaCcnificrr.ofconscnrrosclaln\refoieorkc(conr|Ensarion.ustrcvidcdfffbySc.rionlT0oolth.Lator Codc. Ior rhc p..folnErc of lhc aort ,or qhich rh€ pcmil n h\rd
<br />-l
<br />htrve ud will tuinrain work.il ..'np.nsntn'n insurd.c, rs rcquncn hy Scct i$ :17$ .l rhc Lihor Cod.. r{, thc Pcrfonurcc ol
<br />rhc *ork ntr*hichrhhFrmir is issuod My workcs .o.rpctrs0lion insur.nccca cr and policynufiberdc
<br />Poli.yNln$c'
<br />-rixpir.s
<br />I cdnily rh.r in rhc lf,rronmncc olrhc work hr which lhis pcrmil is hsucd. I \h ll nor.n'd.y riy tcsof irr rny nranncr
<br />s rs ro b.oax sul,jccl l0lhc works! .-nDcn\dnn, hss olCalinrnia. Dd lcN rhd ifl nx,uld hlco.E sul,Fr h rh.
<br />sorkem compcnsrli{nrDmvi\n'nrofSc.riofl:171X)ofrhcli'htr(inlc.lshall,ln hsith.omtly*irhrhoEprovi\nn,s
<br />W RNIN(;: F hrc ro r.ue worlcr collrl)cfl$rbn covcr.-qc t unlawful. rnd sh ll \ubJccr r cNrlrrcr ro dninal P(fllii:s rnd
<br />.ivil nfts ut b onc hundrcd lhousrtrd Jollan ($l0o.O0rr). in rddiri{nr ro rhd.on or.o.rl)cn{riotr. drmr8c( !\ [ovidrd ror rhd:::4Dyfry::,x,w
<br />DICIAAAI,IIJN
<br />I hcrcbytrlftrd undcr p..ulryorl)crjury lhar I s,n licnscn undcr Eovision ofChaptcr 9 (co6nteins *nh Scclion 7uJ0) olDivhion l
<br />of lhc Busircs. md Pmfc$ioos Codc, a,ld ny li.cot k i, tull aore rd effccr
<br />(:(TNSTRU(]TIoN LFNDNC AGENCY
<br />I h.ftby arfirnu.d.r !.naltyofpcrjury thot lh.rc h. $nslrudiotr hadins aEcncy tu rhc Perotiun.c ol rhc work a.r whirh rhi\ Pcfr'n is
<br />hsucd (Scc. :1C97. Ci! C )
<br />AEELICANI.DEII.ABAIIA!
<br />I hot.ryafimhder Fnull, orF.rjury.rc orlh. followin8 dcclr ionsl
<br />Dcmlition Permih Asbcstos Nolificatio. Fcdcrrl RrEuhrbhs (Tnk 40. Pan6)
<br />-Rcquircd
<br />t ncrof NorilEalion
<br />-l
<br />ccnify rhll rhc red.ral dgularions rcsrdins asb.sros rcmov{l uc noi 0ppliclbk ro rhn pDjccr
<br />llk(k ,hn t t "" n^d ,nis
<br />'Dplictrrio.
<br />.nd sr c rhar rhc ntnvc inro,rurion h corc.r I lsre ro ..qly with 'u city and counry
<br />ordinaftes rnd Srare liws rlarin8 lo bu1ldi.8 connrucrn[ md hcrcby dur rcp'c{nrxrivc\ ofrhr\ Ciryand (butrrv r. crrcr trFrn lh.
<br />^,.,.r[*f lril.*:ilil:"vlwq1/
<br />Pemi,Fntrme,prin,): u- 1t14AKtA Jl t4UAt ar->
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Lighl Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER (Mu4 >7)
<br />Transformers
<br />Torqueinq
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />It/eter Release t(n ,n,{qrz '7a)
<br />\\
<br />Rough
<br />Service IVleter u <7D rtT \&.1frqd ?>>)
<br />FINAL ul)o I r( 'i .Y{v )
<br />Notes, Remarks, Etc.fr v\
<br />-'
<br />ELECTRICAL-INSPECTOR BECORD
<br />Sub-Panels
<br />trtrd.iq Addr.rc
<br />-
<br />I
<br />I
<br />tt
<br />It-
<br />llAtfiTu
|