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APPROVALS DATE COMMENTS OWNER AUlLDER DELCARATION
<br />I h€rcb, arfi,m undcr pcnolry of lciury rhor I 0m exenpt lmnr rhe Conlncron Lksn* lj! iu rhe fouowine r..avrn 1s...70.11t
<br />Burincs a"d Pmfe$ion Crtc) Any Cny or Counl, rhth reqlir6 r pcmiit b c.n{ru.r. 61rft, in1proE d.mnnh ,. rcpatr y
<br />smclue, priqro irs ii\u.cc, als. Equircs rhe npplica tuslch Frmi t, fiLa ri8n.d sdc,mm rhar hcor shc G ticcnsc{ pu.\n t
<br />to th€ pmvisions oflhc Conlnclols Liccnrd tjw (Choptcr 9. Comncrcins wilh Sccthn 7Om ol Divirion -l ofrh. Busincs ,nd
<br />Professions Codc) or rhar h. or sh€ iscrcnrpt rhercfrona rnc bork lbr rh. allcscd €xeoFrior, Any vdalionof SNion 70.11s hyan!
<br />arplica rbr a pcmil slbjalslhe apolic! to scivilpcnrllyofnol'mrclhan fivc hundrcddollds($50o)
<br />l.,s owror olrh. Fmp.ny. or mycmplorf,cs eilh waBcs {s rlrl $k.untcnsarion. willdo Inc nork o.d llE srurdE i\ ft
<br />idcdei u of,ercd ttr ele (Sa 70,i4. Bushcs and tt{,lesioF Codc Thc CodBctois Liccn* Ilw des nor ,F!ly lo & oq'ncr ol
<br />rhc tmpcny *ho hoil'is o. inworcs lhcmn. nt who des sEh *ork hiarsclfor hcrslfor rhmryh hn or hcr osn enpl.yc.s,
<br />providcn rhlt such numvcm.rs m nor inrcnd.d or ofloql f.r st. l( h.reE. rh. tuikliry or in{mrcmrr ir bld wilhin nm Fr
<br />of.or{iLrion. !h. Ownf Buildcr will hak rh. buftLn of ptuvi.g rhnt h. or shc did tror build or inrpDvc dE pmtEny for rtE nuqns ol
<br />I. owic.olrhc trolreny, ad.x.lxrivcly contacrins wirh liccnscd codlrrbN rd..tr{tu.r rh. pnrc.r lscc. ?o44. Busir'c$
<br />ml ftoission Codc Th. Gnrrcctoi \ Liccnr tiw docs n.r rnply to m on nc. of prolEn y who h ild\ or ihpn,vct rh.rcon,
<br />ind who conr.Jcr fir such ptuj.c( wnh n Conrncdr \) li.c \dl pursurnt ro rh. Coft0ck sLiccnetiw)
<br />I rcxc rlr ! dcr Sc.noi
<br />I) r O*.r.
<br />ranKl:&t.(auuNtdrr0-ri
<br />DICLIAAIION
<br />I h.rcby rflirtundcr FnJlr) of|f,rjrry.n. ofrhc n,lb$ing d.chrrri{)n\
<br />-l
<br />hovc and willmintrin a CcnifElrc ofConscnr lo Sclilnsurc ao! workcrF Nnpc.qrion, r\ pr.vid.d ror b, scdion l70ooirh.
<br />L0hor C{nc. for th. pcrforroncc olthc work aor whkh thc plrmil h issued
<br />_1tulc rnd silln[i trin workcri.onr|[n\rri{nr insurrnc.. as rcqnncd hyScrii{in.17([olrhc t;$orCodc. ror thc lcrfonnnkc ol
<br />rhc sbrk ntr*hichthi\ ptnnir i\ n\ucd MyNorkcrr comli.nsrriotr insrrlm..ari.r md F)li.t nun$.r u.
<br />PolicyNu'nhcl-
<br />I ccrlifyrhar inrh. rcrtortunccofrhc wo* ld uhichrhis Fnrn is issuod,l ftrll nor cmploy atry lEnon in anymanncr
<br />so s ro hcconE subid h lhc qolkcr conDc.s ion hwsofcaliaomia. and asrcc lhlr ifl shotld bccntu rubjccr turh(
<br />*orkc6' compcnlar ion poli\ionr ol Scclion 3?00 of rhc , ihtr Arlt. I \i!ll. ft'nh*irh omply w i'h rbs pn'vhion\
<br />WARNING rtriturc b surc workcs conrrns ion covcmg. i\ utrhellll. .nd stull \ubjcr !n cmplorr ro oidinrl lrruhk\ and
<br />civil finct u! ro.m hnndrcd lhousnnd dollnrs ($lm.uD). itr iddiltun ro rhc co( ol conrpcnslrion. donrsci a\ Fovidcd titr rh.
<br />S(r'on x',o ni rh. blnr a'odc, rcrc{rod0 onu \14.
<br />D.l.:_ _ _ ._ Appllol: _LICENSEDc6ii cToR
<br />II&q,AAAIII]N
<br />Ihcrcby,fiirmund€rFnahyoiFrJurythltIamlien*du.rpmvhiorofChlplc9(commrcing*nhSsrbn7000)ofDithionl
<br />of $c Busin.$ ed Profcsions Codc. ald my li..ns. is in tuU foE ond crccl.
<br />ATIITANfDECIASAIII]N
<br />I hftty ofiim lndcr pennhy of p.rjury one ot $c followinS dcclffilions:
<br />Dcmlnio. PfnriB-Asb.slos Nolin arion Fcdcral Rcguhrions (Till.2lO. PM6)
<br />R.quircd ldlc. of Nodlrcdion
<br />I ccnilyrl,rrrhc n.lcrrl rcguhrn,n\ frg&llnE a\hc{osrtr vJlrrc a, rptlic$lc n' rhis nnic.r
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />as, Pool, Fountains
<br />Signs (monument)
<br />Lile Sale ty /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding i Groundinq / UFER
<br />Torqueing
<br />Sub-Panels
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rough)
<br />It/eter Release
<br />Rough
<br />Service Meter
<br />FINAL (lrte,// ?I ''ma-rl-,/rrl
<br />Notes, Remarks, Etc
<br />ELECTRICAL.INSPECTOR RECORD
<br />ID/SIG.
<br />Site-Work
<br />Transformers
<br />Air Conditioners
<br />(:(}NSTRUCTrcN I ENDIN(; A(;ENCY
<br />I hcE$y am,r.uRlcr pcnalry.trrjuryrhor lhqe is acon(ruclhn hrdinr lscty lor rh. F nnuftc orrhc work lot shich rhis,r.nrit is
<br />nsucJ (Scc 3097, Civ. C.)
<br />l.nd.a! N m.
<br />I .cnify th,t I h,v. rcd rnis .pplicariotr dt stdc rtu lhc rtDvc informrion is conNr I a8c to omply wirt all Ciry and Counry
<br />ordin!rccs ed slrrc bws Elrrin8 ro building .onmcriob. lnd h.r.by aulhoirc rcfce.rarives otrhis City ond Colnrylo cnld lFn rlE
<br />,liv. trnrioftd pn,p.ny tor insp.cria. puri!*i
<br />Appllcrol or Agcnl SlgMtlE, -, Drl.:
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