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APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELC,TRATTON
<br />t hctoby rnir utulr pcmlry or Frjury rhar I ab.rcm[ rnm rh. (ootrrr(or'Lren{ Llw turtn fnllo*'ns fu$n (sd.70.]1.5
<br />Businc* rnd Pnntsion Codc) An, Ciry or Counly *hf,h rcqurc\ a llgmn h cnFirud. atrcr. rm['ntr.. d.mlrh or rcp3n ony
<br />stflcluc. prior h ns issu.rcc- oho Ealuncr the atdiclnl for suct pc.mil x,lik r {iEicd lrarcm.r rh,r ltor sh. i li$n*d Putsanl
<br />ro rhc F,ririo.! otrr. Conra.ror's Liccnsd hw (Chatrd 9, comnEncin8 with S€dion ?OOO ol Divhi.n .l orrhc Businc* 0nd
<br />Pmfc$ion$ Codc) or rhd hc or shc is cxcryl thcrclrom md tlE l,asis ror rlE lllcscd cxcsprion Any v,DlnrionorScclion?0315 hy rny
<br />apllicant lt'ra pcrmit suhjccG rie bmli.r.i rorcililp.nallrornor mrcrhrn iivc hundrcddollaB (S50O).
<br />I. ns own.r ot thc UlJEny. or .ry enll)loyes wilh *i8es ,s rhcir sle conDcn\arion. will do rhc aork ,Jd rh. {trruE ii nor
<br />inrcndcd oronbrcd lo, slc (s( 7044, Briinc* and Pmrcsion\ Cods Thc (l)ftd.tors Li.ensc 12* docs nol apply r{, ur owrror
<br />rhcpolcny whobuildsori pmvcs lhcmr and wh. do6 $.h M)rk hinKlf or hcnc lf or rhion8h hii or hcr ow. cmllo)ccs.
<br />fovid.d rhri such nnlbwtrEnh drc nol inlctrdcn orofc..d fo. sulc ll ho*cvci rhc hlildinA or i.lprdcmnr is *,ld wirhinnc,a{
<br />oln,mpbiion. rhc Owncr Auiud will hivc rhc burdcn ofpovin8 lhd hc or shc did ml lEild or iqrrrc rhc pn,lcny for lhc purtbsof
<br />Lrosncrofrh.pbptdy,.nrcr.lulivoly.onta.rintwirhli.cn{cdco.rrrr,16t'cotrdrucrrhcpmj.{r(Sc.7lx,r.au{ms
<br />.ft1 PDf$sion Conc nre Conlrrrn s I- i.cn\c ti( docs for l'ply i, un osnd o f ,)loprny sho hlilds or imrovcr rhcrcon.
<br />and sho.o.r F for such nojaF wirh o Conrrrh( n li.cnwl punHnr ro rhc Conrncbis Li..nsc hw).
<br />Lrcxcnu und.r s.cridr . A. & P C. lnr rhi\ rqu,
<br />D6i.: Own€r:
<br />woRKEILS', COIYPn\S,tiION
<br />IIICLABAIIOIi
<br />I hcr.by afinnxnd& pn,hy ol pcrjury onc oilhc folloqinS dcc,r{rion\:
<br />-liuvenndwill'uinhindCcnifi.dcofCo.scnltusclr.lnsurclorvorkcBcomncnslln,n.aspn,vidcdnrbySc.rion]Tm.lthcLohor Codc.ld lhc |*rfoflnonccoflhc worl tor {hich rhc pernir is issu.d.
<br />-l
<br />hrwrnd will rsin'rin wor*cn ..npcnsnrion insunmc. $ rcqutLal byScction]?00 ollhc Lahor Codc. ror rhi PcrfonMncc of
<br />ih. sork ru whi.h rh p.mir is tsucd My *orkcs' conrpcns.lion i.suBncc qricr ad Fnicynumb.r dc
<br />Zr.,-e,.-c.Lr ci Ca. '^*,.u-'uc o13 GgGlo3 la-t- 17
<br />-l
<br />ccnily lhnr in lhc pcrlotrrEom ofrh. w.rk ft, which rhir nrnnir k n{rcd. I shrll nol cnploy an, pct$n in any dMnci
<br />q, asio tf,conf, \ubicr t, rhc w.rkds ..mp.nslrion hss olcrlinnni!. md asEe thar ifl should ltc.m \!bjrt . rlr
<br />N.rkcr on,pcn\rn,n t)n,vhions olSccrion -17tx) ofrhc ttrtn Codc.l shrll. fonhwirh comply qirhrh,* pio(ilions
<br />WARNINC: l,nilurc ro $curc *orkcrs .{mpcn\rrn,n .olcrrsc i\ unhwrul. atrd sh.tl subjccr rn cnrlorr lo dniial Jt rlric{ md
<br />civil lnrcs up to otrc hurdrcd rhousond dollars (SlrD.U)O). in arnliidr b rhc.oi olc.nPctrsalion. d.rm8c\ rs rmvnicd r rhc
<br />sccrh.10T6olrlr tjhtr ('odc. inrcrc( utrl llnmcy s lccs /<A.^.8.\- l? ,,,,u,".*
<br />I h€Fby artrm undcr n nBhr ol pcrjury rhnr Ln lie.\cd undd ln,viii.n of Ch0ptcr 9 (omnErcin8 with Sccrbn 7000) ul Divhion l
<br />or rh. Busiftss aM Pmtcssions Codc. od nry liccns h in full lore and clta.'r
<br />C C/,?16 (rc(
<br />t j-r ,,.Ann
<br />COISIBUGIION.LENDINIi.dGEN.(jI
<br />I heEby afllrm lidcr pcnally .r r.riury lhal lhcrc b . onnrucli.n hnding 0Bcrcy for lhc pcliunErcc of rhc work for which lnt pcrmn is
<br />issucd (Ss.109?. Civ C.)
<br />AIPIII;ANLDES,AAAIIAN
<br />I horby onim undcr lenalty oI l).rflry orc of lhc followi.B d(larar tt.!:
<br />D.mlirion P.rmirs Asb.{os Nolific.tion Fcdcnl Rc8uhlionsl.rnt {O. PUr6r
<br />Rcquircd trkr of t{dificalt,n
<br />l.c.ilirh rhc lcdcr rcguhrions rcgudiog a\bcdo! rcN'vll rc Doi iltltrhlt n, rh,s t'ft,jccr.
<br />-lccnilyrl,rIhlkrcldrhi\rlflkrriona
<br />sl crhd rh.abvc irlonr[io. h.otr(r.I rgrerocomply*nhrllCirya Coutrrt
<br />ordinances rnd Srlrc liws ruL in! r, buildin8 .onnrudnr dkl ltrBby.urhorizc r.tmscntd ivc\ of rht Cir y nnd Coum, b ctrlcr ulxnr lhc
<br />$.rr nrdir cd |[)I)cny iir ir
<br />ADpli.lnl ur A,tenl Si*nnlurc
<br />r"-i|"" ,,n* r pano, K -
<br />,r'1h
<br />4ss icr [Jqt. .
<br />.v-7-/E
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Lile Salety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Groundinq / UFER 'il/lblk lsL-/
<br />Translormers v'vv-
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Faclory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinqs (Hard & Solfit Rouoh
<br />Ceilinqs (T-Bar Rouoh)
<br />l\/eter Release
<br />Rouoh
<br />Service Meter 0:l-t(: hr>[+l\^
<br />I /'u/tb 3lld1l
<br />Notes Remarks EtC.
<br />-t
<br />ELECTRICAL.INSPECTOR HECORD
<br />Site-Work
<br />A
<br />FINAL
<br />I
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