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ELECTRICAL-INSPECTOR BECOHD <br />APPROVALS DATE ID/SIG.OWNER BUII,DER DELCARATION <br />I krcby alfrnn undcr Fnally .r Frjury rhdr I m cr.mp( rmn rhc Conhcro6 l-tens La* for rhc rduo*in8 rc.sofl (S(.7o:ll.t <br />Buri.c\s and Pn'rcssion Codc) Any Cily or Cou y ahich rcqlircs a ftlhir to c.n$rucr. alrcr, impfl,vc. dcmohh or rpnir ry <br />nrudur.. Fr6r lo irs irsuarcc. alw re{tuncs rh. aptlt.nr lq srch Fmi b fik o siSn d {atm.l th hc o. sh. h liccn{d punu,nl <br />b ihc pn,vhi.n\ orrlh Co.k..t \ Li.cnsd tjw {Ch{Itlcr 9. Comm.mins *irh scc(hn ?fix, ol Divnion I oflhc Burires and <br />Pturcso.x Cod.)orlhd hcorshc kexcmpllh.rctionund rhcb6sh tor rh. .llcgcd cxcmrri.n. Any violltion olSeri,n 701I 5bymy <br />rrpli.dnt for n p.nDil subjdslhc lppli€anl lo a cilil Fnalr, o{ nor mrc rhd fivc hundEndol s(3500). <br />-1, <br />!s owmr oa rhc ltr)Fny, or ny cnlplotlrs *irh sr-lcs rs th.ir slc compctrqrbn, will &r rh. wml a lhcnruclw is mr <br />nncndrd or oficrcd ror elc (Sa.7()44. t usinc(s lnd Pror'c$ion\ Codc: Thc Cofu&ror's Liccnsc Lop docs lol apply ro an owncrof <br />thc Dmpcny wlh t{ild\ o, inrl,or tlrN(,nd wlx, dms flch $6A htnscllot hcrcllor lh,oush hn or htr own cmrlDccs. <br />pmvidcd rhrr such infrovc'mnh drc mr i, cDdcd or off.cl for $h. ll howocr rhc l,nildiig or improvu Enr is snd $ilhin onc ru <br />.f.o'ntlcri, . rh Ownft BuikLr will how rllc htdctr .f [oving lh, hc or \hc dil mr tnih or iqftrt. dE pmFny ror llE lrqn{ ol' <br />I. rsosn.r.irh. proFny. amcxclusivclyc.nhcrins *irh liccn\cdcoih.r.sr..onnrud llf, pml-tl lScc 7044. Busmrs <br />okl Enfssion Gd.: Thc Conrrlciir's l-ic..sc Lrw do.\.or trtply tu m o*ncr of proi8ny $ho hrikl\ or i.rln)v$ lhercotr. <br />nnd who conri.lsf.iruch pmtc.k wiln u Codrucro(s ) li(cn\cd pur\$nr brh.G)nt..rof{ Liccnsc tiw) <br />I L rrcid undcr S(ri( n ,ts A P('htrr\^(.$n <br />Dat.r Owner: <br />wonxF4ll (:(rniFNs Tx)N <br />DE(:LAI'ATION <br />I her.hy afrir und.r,rnrlryofnqJuryore otrhc n,lhwin8 d$loarion\l <br />I hrvcuid * itl tuinrin a Ccdif.arc ofCon*nt lo Sclllnsurc lin sorlc^ c.'nFisdtrn!.ns Pmvidcd tot hySsrtun.]7rX)orrht <br />litxn Codc. for rtu Fnnrnuncc ur rhc vork tu shich rh. Fnnir is i\suBl <br />4:h \c rnd aill nhn rin $.rkcF conrD.n\rliotr iNnrrn.c. $ rcquircJ hysc.rn :17(x) oflhc rj6or Crdc. for lnc ldot.Etrcc oi <br />*ork rn *hich rhis p.nnn n issuol. Mywor <br />). <br />dt0z <br />l.cnifyrhnt in rhc pcrtuLnDrccofrhc s.rk tu whi.hlhh p.nnir t irsDcd.l shall nor cmtloyanrrcr*,n in rny nrtrNr <br />$ $ h bca,m suhjcd ro rh. worrd{ .ompctr{ri, lassorcrliioni.. rnd lsrcc rhi il t \hoxli tr.onr subj.tr l.th. <br />workcN conlP.n\lti{nr F.vision\ of Sc.rion l?m ol rhc Lntttr Codc. l sholl. fonh$irh c.mply snh rho{ P$vnioN. <br />WAiNIN(;: Folxrc b ecure $orkcr\'conrpcnert,n &ltrsc i1lnhwrul Md (hall suhrcl an cmnLrr h fimnd trMlli$ otrd <br />.ivil nncs trp h onc hundr.d thousud dou$ lll(x),lxx)). in addirion h thc con ofc.mlensrlion. dr'tugcs 1\ prcvidcd tbr thc <br />::::'Yvqfr#-^,ru*r,[ <br />DEII,AIAIIOU <br />I hcEbyamrmundcr pcnulry of pcrjnry r har L'n li(nsd und$ rmvkionofChdpr.r I (6n@king eirh scdion 7000).tDilisn,n l <br />ol rhc Busincss 0od PmfNsions Codc. ad ny ltc.* h in tull f6re !d .fter <br />,,., <br />-"."."*r.*, t -[ <br />o,L." - 'b/ 1 <br />C!}NSIAIJCIIONIENDINGAGEICI <br />I hcrcby ![tn undcr ri(nalry or norury thatlhcn is s cotrslrucrion lcndins osc.cy for rhc pdronMcc ollhc work rot whi.h rhk pfinrir h <br />ksucd (Ss. -1097.Civ. C ). <br />ATIIICAXfDECLAAAIIQN <br />I ka$y ltrtrn und.r pctrrhy of pcrjury one otrhc folloqing dccl0.!rionsl <br />Dcmlni.n Pcrmirs Ash.nos Norific,riln Fcdcml RcSularions (Tilc40. Pan6) <br />-Rcquncd <br />llrrcr ol Norifkarbn <br />ULt * t\ <br />iry rh{ tbc fcdcral rcSulalions rcsudins lshcnos tumvdl drc no' amlic.blc to this !mj.rl. <br />rhsr I h!rc rcod rhis applic.rion ad srarc rhd $. abov. informdion is cotrccl I lgre rosmply wirh allCily rnd counr)' <br />trd Srrre L!w\ rehriry n, huildi'rg.ntr{d.ridr. rdhcrcby.urhrriu ofrhi\ Cny rnd Countylo cnlcr llrnr llE <br />uh,vc rtr!oncd ptupcny t)r insp.dion <br />AIIlicnnr or \[fnr SirMlur. <br />Pemirecn{rtrpd r !(oa C\4\417lq <br />Sile-Work <br />Underoround <br />Pole Bases <br />Lioht Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Lile Salety /Low Voltage <br />Fire Alarm i Dampers <br />Communications Cable <br />Building <br />Under Slab i Floor <br />Bondino / Groundinq / UFER <br />Transformers <br />Torqueino <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unil <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilings (Hard & Soffit Bouoh <br />Ceilinqs (T-Bar Rouoh) <br />Ivleler Release <br />Rouqh <br />Service l\lleter <br />FINAL 4lllltv.-U*rd / <br />Notes, Remarks, Etc.l'l <br />-+ <br />COMMENTS <br />O <br />( <br />Lcntls . N,rc <br />- <br />I cndcr'lAdd($ <br />- <br />-------T------