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APPROVALS DATE ID/SIG.OWNER BUILDER DELCARATION
<br />I h.rcby omrm undcr ,{nolly of pedury lhor I 0n cxcnfl lmnr rhc conractoN LiccnE Lrw tbr rh. lolloqin8 rcr$n (Scc.?0.11.5
<br />Busincss Md Por.s\in Codcl ny Cil, or Counry whi.h rcqltcs u Fmir ro .ondtucr. dltei innn,vc, demnish o. rcpdir dy
<br />slrucrurc, prior ro ns i$uakc, ,lso rcquics $c amli.anr for su.h Fnbir b nl. , signcd sar.,Efl lnar he or sht iq licc.scd lruN{.r
<br />ro rhc pii,vi\bns ofrlr Cook8du\ l-i.cn{d lj* (Chaprc.9. Commcrcins wirh Sc.ri.n 71Xx) of Divnbn I ot rh. Bxsind* and
<br />Pmf.sions Cod.) or thrr h.or shc is.rcrqrr th.rcfromdndrhc blii\ forrhrdllNAcd.r.mpri(,n AnyviolarionofS(lirn701l5byo.!
<br />lpnlicanr Lr a pcrnit suhjcck lh. opplicunl lo icivillcMlryorno. nrrcrhd nr! hundr.d dollds(i500).
<br />-1.
<br />trs o*ncroflhc pnFny. or nry cnDlole$ pilh w08cs as lhcn sb con{cns0lion. willdo thc wck ar/ thc ntrrw is nn
<br />i' .nd.d or ofl.rcd for elc ( SE ?044, Brsincs and Profc$bfls Code] Thc Conrracroas l,iene Lrw d.cs nor rpply r. m owncr or
<br />rhc pmFny wh. build\ or itrpmks tlEcx. rfrlwhoddssch k,* hnnsclf or hcMlf or rhmugh htr or hcr own cmployccs-
<br />tmlidcd 'h!r
<br />\uch imprcvcrnk m mr inrctrncd ororc,ri ro,eh.Il h.ErcL rhc hoildine or iqmrcmnr hsldwirhinonc )rr
<br />oI coryhtt'n. thc owncr Buitlci will hovc lhc htrdcn ol pmving rhn h. or sh. did mr build or ir{,oE dc pmFny lor lhc ptrrrDc oi
<br />-1.
<br />nso*ncrollhc oopcny. omcxclusivcly.o.tradin8 rnh licctrs.d .onlrrtn ro connrud rlr pmJd (S.c. ?O,r-1. 8u\nr\\
<br />a*i P$f6\i.Codc: Thc Cdnrack rl-i.cnscLa*doerfrn.tplyhxnoencrofF)I,c y sltr brild! or inrlJrov.s rh.r&[,
<br />rnd who.o a.Glnr su.h Eojcch wiih. Conr,cbir lic.n*d pur\umr h rhc Conrmdois Li.c.sc L,w).
<br />-l
<br />amcxcnr undcrSc.rion-. B. & P.C. forrhis rc.str1
<br />Dole ()*n.r
<br />woRI<rRs, carl|iIENsAiriiN
<br />DECIAIAUA!
<br />I hcrchy rlfifln undcr pcnrxyolpcrjulyonc ollhc following d.rlearions
<br />-l
<br />hrvc d will nDin'atu a crcnifEarc ol Cotrsnl to s.lfl nrue br sorkcn conD.nsalion.{s tovidcdlorhySsliool7(xroflte
<br />t b.r Cdl.. for rhc p.ifornun c of rlr work for whkh rh. pcrmir k isru.d
<br />_lhavclndwillmninhinworkcrlco.Dcns.lioninsunncc.,srcqtrtdbySc.lionl7(x)o
<br />'h. s l litr trhch-rhn lamir i. h'uct. M) ynrlc^ lnnFctr\u(mn trFurcn.c (Jtricr Jnd pol
<br />."".. . ttt \.., {.
<br />,f lhc Lshor Codc. for lhc pq{ornane o{
<br />- \-\-\?.]qL[,\-a)\.O
<br />-l
<br />ccnlly r[{l ir rhc Ennrlnrn.c oirhc qork lor wh].h rhis r$nir is i\nr.d. I drll trol ctrd('y
<br />^try
<br />pcmon itr nny 'nrnNr{, x\ h hccom uhjc.r
<br />'o
<br />rhc $orkc' i conlltrn\ari{,n la*a or Cililon,ir. rnd r3r. rhrr il I \hould hccotu \trhJccr t, rhc
<br />wor{r^ contFnsrrn,tr F)rni{,n\ .f Srcri,n, :l7lX) of rh. l nhn Codc. l \I.;,Ll n)nh} irh onr y *irh rh.* t(,vnion\
<br />WARNINC: t'lilurc h c.urc uork r coflrEns0rion.orcrqrc is unhwrnl. rtrd \hrll subtccl ir c.ulo)c.lo cri inrl ri(mlris rnd
<br />S(ri(r]076 ollhc lnhr ({xlc. n crcd rrlrrtnncy \,ic\
<br />DECI/f,A1UlrN
<br />I hcnhy lnflnuM( pcndlryorFrJury rh,r I Mr Iiccnscd uodcr poviii.i .l Ch,trd 9 (cofl.rncidg pirh S.crid! 70m) ofSivision l
<br />or rhc Bu\inc$ afld PDn$ions Codc, adl my li.cns k h tulllbremdellcct
<br />r-i.cf\. ( hs: ' / ro .3 l.i.rf\cNu,rrr: ' (oz q L,q \1
<br />o".'k-)?-\8
<br />I h.rcby,mrm u.df pcMlryofFrjuryr
<br />issucd (Scc.109?. Civ. C.).
<br />..",^"*,*:.-:A-:
<br />Z.
<br />CaNiIX.ULUI)NII"!DIXCTIC!;III
<br />hrt rhm n r.or{rucri{r lcndirg x!.n.y lar rhc l)lrlannrmc orrhc s.rk ftn whn r rhir Nnnir (
<br />AIILICANLDECI.AEAIIIJX
<br />I Myrmmnoder pen,lry.rp.rjnry.nc.rrhe rollo*ins d(ladrions:
<br />D.mlirion Permils Asl,cslos Notificalbn ltdcrllRe8ulations (Tillc 40. PM6)
<br />-Rcquned
<br />Lelts o, Nolifrotion
<br />-l
<br />o.nili rhnr Ihc lcdcrqtc8ohrnnB rgddinE !\hc\ros rcR,rll arc nor lpplic0blc ro rhh pmjccr
<br />fryll \cnrry thd Ihdrc Rnl rhr dmlrftnn.nl qrr. rhar lh. rh,v. inntr.Dri, ir cor(t. I a8N b .omply wirh {ll Cily ann Counly
<br />ordinrrccs a.d Sr.r tjwr Blsring lo building ..nnfl..io.. 0rxl h.rcby aurhtri2. rcp.sc.rarivcs ofrhis Ciiyand Counryro enrq uJnn rtE
<br />D"",. 8'4-\8rh{r frnrioncJj)n,ncn) f,tr in\nc.ri,,n lruArr _ _
<br />,rpp .unr".,rs"nrshnuru*.y4I..'- >==--'
<br />pcmi,.rmm.prin,,: X- A--iL,,*, I)\<'trr
<br />Site-Work
<br />Under ground
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltage
<br />Fire Alarm / Dam pers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Translormers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilinos (Hard & Soflit Rouoh
<br />Ceilings (T-Bar Rough)
<br />Rough
<br />Service lVleter I
<br />FINAL I Tholk 1 inh,/t*)a,/
<br />Notes Remarks, Etc.
<br />-,
<br />ELECTRICAL.INSPECTOR HECORD
<br />COMMENTS
<br />lt/eter Release
<br />or".. b- Zd -\ d
<br />Lxndc, e Addrs
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