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APPROVALS DATE COMMENTS OWNER BUILDER DELCAR,\TION
<br />I hcrcby amrflr undcr pcnohy ot Dcrjlry rh.r I m cxenrfl fronr Ihc ConlrucloN l,iccnse tr, r(r rh.ldlirwin! rc0on (Scc 70:rl5
<br />Bu\nhs and PnfDsion Codc): ny Cny .r Coumy $hi.n rcqunc\ r Frnir k .on{ru.t. dlrcr, nnl)()vc. demolish or rcIai y
<br />slD.rurc, rri.r ro ns icsurmc. aho rcqutcs lltappli.a lor su.h,Ennir ro filc0 stncd slilcnEnl lh hcorsh. ir li.cnrcd prBmnr
<br />ro rhc pmvisn,nr otrh Contrcnr r l-i.rns.d bs (Chsprcr 9. Com'mi.ing *ith S..rion 70OO of Divisio.I oa rhc Au\incs rnd
<br />Pnt$hns Codc) or Ihrl tE or shc h.re'nfl rncrcfnnnotrd ihc hrsh forrhclllc8cdcrcmprion AnyldJrbnorsdrnrnT0ll5by..y
<br />amlicanr iNapermir slbjEt rhe applicrm b acivilpcntrlryotnor nmrcrhnn fivc hundr.d dollnrs($500,
<br />-1.
<br />as ouns oi rhc pnPcn!. or my cnplolecs wilh sr8cs !s lhcir solc conDens,r ion. will do rh. *oik md rlE {mturc is ml
<br />inrc d or oflcrcd fitr slc (S( 7(]r4. Bu\incs s.d P,oacsions Codc Thc ContNttr s Li.cn* tiw dms not !p!ly lo m o*rcr oi
<br />thcrd,tEny wh. boildlor inpoEs llEm.. oxl who d@s suh w& hnnscllor hcr*lfor rhmush hh oricroun etrll)k,ycc\.
<br />providcdrhlr slch inrrowmnrx G nol hrcndcd or oltrn h, $t. lt ho*ec. rlE htikline or itr fiohfthr is $kl wirhr onc )ur
<br />olconrtnd iotr. lhc owncr Bui s qill l[rc thc tdltctr of pmvnB Ihar h.orshcdid norttrildorimprct rhc pmrdy for rtr puqbs or
<br />I.AosncrofihcIropcny,ad.xchsiv.ly..ntacrin!*irhliccnscd.oftncronro.\,nnru.tlhcpn*d(Scc?O1,1.Bulocsr
<br />rnd Eoic$ion Code 1 ht Conrractof \ t.iccnsc l-aw docs nor omly ro !n o*ncr of poIl.rr, *ho hrilds or impr.\B rhcrq,n.
<br />rnd who conrB.rs f(tr soch pidjers wirh a Cdnrmk(s) li.co\cd rur\ud ro rhc contdor's Liccnsc L!w).
<br />-l
<br />umcxcrltr lndo Sccri.
<br />.]lsarli&trl,}tfrNtaJlaN
<br />DICI.II3AIION
<br />I h.rch) rlltntrndcr l^-nrlry ofNrjurtoic ofthc fi,ll,,wing {tdclrrdidx
<br />-lhavcajdwiuroinlai"!CenificlrcotConsenrroSclfln\uEtn,*o,k6aconnn{irn,esrmvidcdrorbySccrionl7(rooirh.Lrhor Codc. for thc ,crfomnce of lhe qolt fo! which lh€ pc.mir is hsucd.
<br />fth,!e d will nai.rai, wor*c( .orp.nsarnrn iNnnncc, as Equir.d by sccliotr l?m of rhc trhor c( e, fo! rhc p(nnnuec or
<br />rlf s(trk for shi.h rhir pti'Dir is issu.d My porkcn .onUcniariotr insumR. cmtr ud p.l6y numhcr ae
<br />,,,,,.,'J.l"t F.-^^J- (-*'.omsr[ro
<br />T l.l ,L"rarftfr ll
<br />I.cdilyrhd r rltr ncrlo mNc ol lhc work hr qhich rhis pcirnil is isucd.l shall Nl cnrtlo, tro, ,.r{n, in rnynrtrncr
<br />$ D\ n, nronE \tr|*cr ro rhc w(,rkcis ('npcnsibn hw! of(-alifirnia. rnd a8ftc rhd if I should h.com subjd h rtr
<br />sorlc.i lrnnpcnsrrbn pnvirn,ns of S..r ion ]700 of rh. I f,hn Cdlc, I tull. f.nhqirh .l)nlrly wirh rtFc polisions
<br />IVARNIN(; Frilurc n, {crrc {ork${..nr$nsnridr.ovrtuBr i( rtrlxwtul. d n[l] {'bl..r n cnD[,ycr ni cri'ninrl tf,nrlricr rtr
<br />uliflr. innr.gcs rs pn'!nlc,l lnr rltrcilil ftr.\ uI b om hundrd rh.u\rdd d.lh^ (Sl(X).l Or. ir r.Uirnnr ni rlic.o{ !n (,
<br />,r,,. - GLt ,lXlllo rt
<br />D&CIdSdIION
<br />I hcrebyamrnundcr pcn.hyofrcrjurr rhar I ad liccnrd lnder pmvhion olChrprd 9(.onrmcncing *irh Sc.lion 7000) ofDilision:l
<br />ol rh. B$ines .nd Pmfcssio.s Codc. aid my li$trs is in tull f.re ori cffccr.
<br />0r0
<br />'Ot(.rqbott
<br />CAISIAIJSIIANIINDTIG.AGEII:I
<br />I hcEby aflnm undcr pctralryofpcrjuryrhol lhcrc is a con(rucrion lcndin!,sc..y lnr rhc tdr.nnancc ollnc wort lirr Nhich rhh Frmir h
<br />nsucd (Scc 109?. Civ c.).
<br />AITIIIANI.DECI.AMIION
<br />I hcftrrry afimt xnd.r FnaIy ofrnjury onc ofrhc lilllowin8 dftlarurioni
<br />Ddmririod Pcrnik sh. or Norin.arion F.d*.|R.gul io.s (Tnlc 40. Pan6)
<br />R.quimd t ncr of Norifi.dion
<br />-l
<br />ccrrify that lhc fcdEalrcEuhtiotrs rssrditrB asbc(os rcmvularc nor aprlkubh k, rhis p6iNr.
<br />lll cdnirr rhar I hrv. rcad rhis applic,'ion,.d {ar. rhd rh. abov. inro.mrintr is.onRr.l trgN locomtly wirh rlr cirytNl (ou r,
<br />.'di'rncc\ r d SIdcl-*v\ rclri gh huildinA.orn'x.rnL Md lrrchy ?. rcprcsc.r.rn!( oirhn Cilyo'd C.unry t, ctrr.r urx,n rhc
<br />rhor. nrnrnnrn pmI['1y ftn i'rsfo.ri,r fu'tx'sc\
<br />Appllonl or ASent Slgnature: X
<br />e"*i,"" n"."lr.in,,, X 'f"L +h
<br />,,,", , 0g bt l"lo,g
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Liqht Standards
<br />Spas, Pool, Fountains
<br />qigns (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding i Grounding / UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rouqh)
<br />Ivleter Release
<br />Rough
<br />Service lvleter A
<br />z /.tzFINAL ld nM 4f)
<br />Notes, Remarks, Etc
<br />ELECTRICAL-INSPECTOR RECORD
<br />ID/SIG.
<br />L.ndc'\Addr\
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