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APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI-CARAAION
<br />I hcrcby amrm lndcr leMlry of pc,jury rhd I an.xcofl n o rh. contlcror' Li€cnsc Law lor lhc nnbwing rca$n (sN.?0J1.5
<br />Busincs md Proie$ion Codc): Any Ciry or Cou.ry which aquircs a F.nnr lo Llnsrdcr, alls, imF)vc. d.nmhh '{ mlrtr 0;y
<br />srrucluE. r,hr ro irr irsuarc. alo dquncs !h. +plhd rd $.h pcrnil ro filc 0 sismd sr cmnr rha, h. or \h. is licctrcd pusua,lr
<br />b rh. povNn,n\ ofrlr Conracktr s Lietrscd L.w (ChBrlcr 9. Commcn.i.! wirh sc.lion 7uD of Divhhn I of lhc Blsincs !.d
<br />Prufc{sidrs Co'lc) or lhol hcorshc iscrd.rtr rhcr.iio rdrhchsisrorrhc,lLScdcxcmprion Any violsrbootseit nT0ll.s byony
<br />rrtli.dnr ri,r a pchlit sublcclsihc amlicanl ro rcivilpcnallyofnol morcrhon lilc hundJed dolh* (55m).
<br />-1.
<br />0s ownc! ollhc pmpcnr, or ny.npb)tc{ *irh wa8.r ar rhct vrc .on{'ctrH[nn1. *illdo rhc *ork lnd rh. srdurc is mt
<br />inrcnd.d or o&crcd for sdlc (3(.704,1. Busincs and Proltssions Codc:Tfu Co ra.tois Liccn* Law docs nor apfly ro an o*nc..f
<br />thcF'pcdy *lm toildr or inlpm\ts rhcRrn, rxt who del such mA hnnrllfor hcFcllorlhrough his orhcr own cnllloyccs.
<br />fn,vidcd rhrr such inrrroEEnh e ,ol intcnd .r oftcr.n fo, eh lf. ho*o.r, rhc brildinA m in\mvcnrnr is $kl wiihin orc tar
<br />olc.n{,lcrion. rts O*ncr Buikln will har lhc hndcn ol Eoring thd hc or +c dil ftn t ild or inptuvc thc fmlrny for lhc puqns of
<br />-1.
<br />!\o*'E ofrhc Forcny, dm.x.lu(ivclycotrkrcrinS snh licenscd conrrucl,,rlo.ti{flcr rh. Pmrcct (Scc.7044. Bunocss
<br />ord PtnLssiotr Code:'Ihc Conrrsclois l"i.cnsc l-aw do.s nor,ppl!ro in ownct of rroFrry wfio huilds or imrdv.s rhcrcon,
<br />Dnd who &nirdcB ror such pr+ch wirh n Conhclo(s) liccnscd rusunr ro rh. G,nrdcin\ Licc.s bw)
<br />Dnle,_... ORm.:
<br />w(lRKFRs' coltitrNaiiitrii
<br />IIICLIIAAM!
<br />I hcrcb, am,n!.dc, pcnalry or p.rrxry orc olrhc folloqi,B rkclffilnrns:
<br />-l
<br />havcunwill mlinrainaCcnifrar.ofcon\..iro sclf-lnstrrclm qorkcr' ompcn{lrion. a\ pmvilcd tot byscction l70o olthe
<br />tit$r Colc, for lhc pcrlolmncc of ltc work for whth rhc pcnnir k h{rd.
<br />I hnvd rid will nri nir sor*crl conrt ns.lion insurancc. a\ rcqun d bySkrnJnlT0Oolrhc ljhotCodc.lorrhc Pcrfomr..c of
<br />rh. u.rk nn whi.h rhtmrn is is$cd Nlyeorkrri coffcn\ i,,tr nntrrr cc I
<br />4"
<br />V rL) Cg Q za\_2q
<br />I .cdiri rhar in rhc pcrformnNc ,,r rhc work fi, *hich rhi\ r.roir rs ir\urd. I sh!ll nol cmrloy rny pcron in n.y nrMncr
<br />v' 6xrEqoE subFr t,rhc workc^ .onlxnsrrtun lnwsofcrlilarni{. rl lararhrr ifl\houLl h..ont {hrcd rolhe
<br />$or[.ri d'nrpcnsrion F,v]lions of SLdn lTmnilhctit C(dc. I \hrll. tunh$irh co'n l] wirh rh,{ ,ov^i.n\
<br />WARNIN(; Frilurc to rccurc qorkc^ conDcnsJlion colcragc i\ hlr*tul. nnd $r1l subic.r (I cmplo)tt ro dninil FDhi.s rnd
<br />civil fincs u, io otrc hundrcd thousotrd doll$ ($100.0(x))
<br />sc.riotr 1076 ofthc tjbo. Codc. inlcrc( lod lormy s lee\
<br />irn k, rhc .o{ ofmmncnsrlion- danEx.\ r\ nnrvidcd lor rhc
<br />I hcr!6y (l6nn udcr Ic alrl oi pcrjury rhnr I ah lic$a'd indcr tmvision ol Ch.pler 9 (mmmncnrs wirh Sarbn ruxJ) ol Divisio. l
<br />ot rh. Businc$.nd Profc$ions Co'lc. a{d myliccn\c is in lull f{tre ad cridr.
<br />o
<br />M c-i"*r.",K<E-L\iq E2\kr4\j0
<br />COIIIIIJCIIANIINIIINC.AGENCI
<br />I hcEbyalnmundcrrcnlltyoIpcrju.ytnai rkrc i\dconn crionlcndin*.8cncyforlhclcrfonumcofrhcworklorrhichlhirpcrnrilh
<br />ksu.d (sN 109?. civ c.).
<br />AI?LICAIIDECLAf,{IIIIN
<br />I hcatry 3[im undc, F.alty oa ,.rjury o.. of lhc folhwnrg d(hril ions
<br />O.mlilion Pcrmits'Asbcstos Norificsrion Fcdcrul R.gnl,rions (Ttlc 40. Pon6)
<br />-Rcquircd
<br />Lettcrof florilEulion
<br />_l ccnifyrhar rh.fcd.rrlrcgulrrio.s rcBrding astEsosrcnnvil c nol arllicabh b rhls t6l.rr.
<br />rfE l..n,rJ rh,r lhJvc rcad rhh rydEa,i'r, md rdrc,h rhc,tdc,nr, rur'.lN,.r..r l,BBhsrn.
<br />trilii-c'c\ rnd sr r tju\rl,rne h.burU'nE c.nidchrtr. rld l.crcb) iurhnr/c rcfre\.nrdtrnorrhtrC
<br />abvc nEdi()ncd lropcdy for insFcr
<br />ArDlic.nt o. Aa.nt SiaElurc:
<br />n"-r,." nunr" ,r"u,,, (>--!j-e rz\K-A
<br />^
<br />Ace
<br />y wirh allCnylnd G nry
<br />) e',r cud) b mh uTlE)
<br />oK -4:Y
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bondinq / Groundinq / UFER
<br />Translormers
<br />Torqueinq
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)to/r.r/E t4tx-a-/t2-
<br />Walls (Rouoh)L A
<br />Ceilinqs (Hard & Soffit Rouqh
<br />Ceilinos (T-Bar Rouoh)
<br />Ivleter Release
<br />Rouoh /t/ul*GYtte-./@
<br />Service lvleter
<br />FINAL I TPzh,r .AMb-/:.'.'-/
<br />Notes, Remarks, Etc.
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<br />ELECTRICAL.INSPECTOR RECORD
<br />_l xnrcr.nu undcr Sc.toi .B &PC lhrrhnr.!{r,
<br />*",-o{ 6 - l{
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