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APPROVALS DATE OWNER AUILDER DELCARATruN
<br />I hcrehy aiirm lnicr I'eMlr, ol lcriury lhal I am crcmpl fmm rhc Contudon l-iccnrc Law for thc lollolins Es,n (Sdc 70-l I 5
<br />atrsincs ml Pi.fcssion Codc): Any Cny or Couniy shi.h rcqoncs Fmir kr mn{ru(t. alr(, ifrprorc, dcnxnish or Eprn M,
<br />nfldurc. pritr r. ns kuan.c. rho rcquircs rhc aprli.ad r.r sxch Fnnlr ro fiL a sigtrcd ndcmnr lhal h. or sh. n kcnscd ,)unuMt
<br />r. rhc lrolirbn\ oI rhc Conr6ckr's Liccnscd l-a* (Chaptc! 9, Commcrcins wirh Sccrn,n 700{).f Divirion:l orlhc Busincs dd
<br />PmlcrsnrsCod.)o.lharhcorihcisrrcmptlhcnrromaftlrhcbdchrorrhcall.g.dcrcnrplion.Anyriol.lbtrolSdion70.115byan,
<br />applicinr for.Frmir subJslslhc !p!,ic0nl lo acivil pcnohyofnor nbrcthm iivc huodrcd doll.n ($5(n).
<br />L as osnrr of rh. poFny, or hy cmpbyc.s sirh wrE r as rhrir ek ..n{rnsr ion. will do OE wrt .flj th. sB1@ h nol
<br />inrcndcd or olitrcd for slc lsc 7044- Ausincs dd Pmlcsrbns C.nc Thc Contrrols Li.cns tiw docs nor anply r. an o*ncr ol
<br />lh.lmNnl who hilds or i'qnohs rlson. rnd wh. dms s.h M him\.ll or hcr*lf.r rhtuugh hk or hfi own cmployccs,
<br />ln,vidcd rhrl such impmremnts @ nol inrcnded or oftcied ltr eh. Ii horcv.r. lh. huildiry or impmrcmnr is sU eirhin onc r&
<br />oi con{,lction, dc Owftr Buiklc, will haw rh. trnlcn of poving rhd lt or $c did nor buikl or inpoE thc pmFny for thc puqx'sc oi
<br />_1, a\owmrof rItr lroFny. r cxclusivclycommcrin8 wirh liccnscd conrarlos x, cotrrflct rhe ImFcr (Scc. ?04- au\irE$
<br />a hots{,n Codc: Thc Conlracld s l-iccnsc L!, docs nor appl! lo m owncr ofpmFrry *ho bxilds or in,nrcv.q rh.r&r,
<br />and who.\ ra.h ror such p$j{h *nh a Conr6.kdn licei\cil ru(umr b rhc G,nracrors Licc.sc tjw)
<br />I rncrc rt, trrd.r Sc.li,rl
<br />D.ler Ovm.:
<br />}I)BtrEBSI:AIISEITIAIIQN
<br />DECIAtrAUAN
<br />, hcrcby rflirnrundcr pcralryofFiuryom ofth. following ddlnra(i.ns
<br />I ntrw
<br />"nd
<br />will ruinrain ! Ccnilic,rc olcon*nr l' Sclflnsurc ior workcB co'nljcnslrio.. ar lrolidcd ror bysc.rion 3?00 ol rh.
<br />L xtr Grtc. for lhc Frfonnancc olrhc *ork ror which rhc Ennil is hsud.
<br />lhalctrnd will mainlain workrs. .omp.trsarion insurd.., ar rcqutcd bySc.nonlT(nofrhc Lihor Codc. for the ncrlornuncc ol
<br />rhc work lorwhi.hlhis p.rmir is Gturl. M, wor*cr' ..n\rnkt io. insuru.c .rnim dxl Flicy N mb.r m
<br />I ccnii!rh.r inrhc,.rLirniNc ol rhc vork lorw rhrhisr.rnil is issucd. I nrill rorcmploysnypcrsn inrtrym0nncr
<br />s 6 to tEconE sublcd lo lhc *o cs comtcnsar ion kws of Calirorni& otrd UB lhal if I shoub h{to'rc slhlc.r ro rhc
<br />wolkcG'compcns0rio.prclkionsofSdiotr3TmofrhctjborCodc.Ish.ll.fonhwilhconplywithlha$Imvkioos.
<br />.Nil lnr\ trJr ti ,tri. htrndrcrl tltr)!\rid
<br />\..iL n)r. "1., htrtitrl rhlt{
<br />^,.,. s/rrltr
<br />,tr lo diminal lEmlli.s rnd
<br />.m8es .s ,mvllcd for lhe
<br />IIEILABAIIA!
<br />IhcthyiftmundcrFnrhyofpcrjuryrhxrIrnliccncdundqnmvisi.nofChrprcr9lconrnrnci.E*irhScdion70OO)ofDirino:l
<br />el)e
<br />CANIIAI]I.:I()NIENDINCICENCI
<br />I hcrby rlliiin undc! Fn,h,ofncrjrq rhsr rhsc i\ a con(ructi()n lcnding r8cncy li)r rhc I.rfornlai...frhr work ibr whi.h rhis !.rnrir h
<br />ksucd {Scc. 3097, Civ. C )
<br />AEELICANLDES.AAAIIIIN
<br />I rri$y amnn undcr I. alry or p.rjury .nc or rhc lbllowin! dchrur ion\:
<br />Demlition Pc.nrirs-Asb€sros Nolificdion Fedcral RcBulllions (Tnlc 40. Pan6)
<br />Rcquircd L,!terol fioriararbi
<br />l.cnilvth rhclcdc(lrc8Ul irrN
<br />-l
<br />ccnilyrhnr I hlvc lcld rhn rnpl
<br />ordin.nccs nd Slarc La$srcliriqto
<br />orcd lrgreb.oNnly wirh rllCirr-r Counrt
<br />.hovc nr iotrcd pmf.ny lnr
<br />.\pplirinl or,\!rnl Sixn"lu
<br />A.-,, t e\<-t L-Y
<br />-:':'::ry[;"
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Founlains
<br />Siqns (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilinqs (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rough)
<br />lVleter Release
<br />Rough
<br />/')
<br />FINAL
<br />^t>l
<br />ft1 ixr.ol '7vl-t I urlNotes, Remarks, Etc
<br />ELECTRICAL.INSPECTOR RECORD
<br />ID/SIG..cOM[{ENTS
<br />Service l\ileter
<br />or rhc rrusimss and Frcrcsions codc. ad my riccns is in fun forc andj]}:cr.
<br />I
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