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APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION
<br />I hdEby lllrft undcr pcnilry of Frjury rnol I or cxemfl lun lhc Conrs.fuF Licctrrc Low lor lhc lollowing m$n (Scc.7ol l .J
<br />Bu\incss ,!xl Prof.sion Codc)r Any Cily or Counry whkh rcqutci r trrinir ro mtr(ruc|. alrci imptoli thn,lkh or rput iny
<br />rh.luE lrirt its issu!tre. oko reqliB\ rhc aptlklir ir \u.h lfrnrt lo fiLa sisncd slarcft lhnr h.orshc is liensed l,!6ta.l
<br />ro rhe Fovisioni of rh Cdnractols Liccnsd tir (Cho,,lcr 9- Commcmio! *irh s.crion 7000 of Division I orrhc susincs ttrd
<br />Pn'lc*iotrs cod. ) or rhar he orshc tcicmnr rficrcr'mn and rh. b€\is for rh. ,lk8cd cxcnurion. Any violarion ols(tbn 70115 h, any
<br />aprliclnt ior !lemir suhjccklhc rrtlic,nl ro acivilp.Mlryoinor fttrcthan livc hundrcddoll0B($500)
<br />l. N.wncrofrhc pm|Eny.or ry enrplorE\ wnh waB.s ,t rhcir slc onwtrslion. will do lhc wort dd rtr YMN h ml
<br />i.dcrl oroftrcd lor sk (Sr.'.7044, Boairess,nd Prorc\1ions Code: Thc Co rocr{, s l-icen{ liw dds tro( {Ply to an o*icr or
<br />rhc pmrcd, sho hnilds or in{mvcs tlL]1M- and who dms s.h mrl him{lf or h(sclf ot thmuAh his or h.r oancmployes.
<br />F.vilcd lhol such impnrcftnh d ft, idcndcd d ofincd ior nrlc lt howcki rh. boildi'r8 or irnnmrcrEd h $ld $irhin un( FJr
<br />ofofl{,Lrbn. riE ow.er Builkr will has ttr bxdMorp vine lhd lE or shc dil mr l{iu or iqn,r ih. poFny ror th€ PurF,s or
<br />-1.
<br />as o*Nr ol thc ,nopcny, r cx.lu{ivcly conlndir8 wiih liccnrcd coorracn,\ b con{ncr rh. toi{ (Sa 7l)4.,r' 8u\ift+
<br />and Ptr,rcsionCodc ThcContnctols Liccnsc Lr$der nol!!plrro aiou orltoP! yvhohuildsorimlmvcsrhcrcon.
<br />rtrd who conlrucrsfor slch pmjNk wnh a contia.ttrl, li.cn*d Puisuinr lolnc conkD.ttrt Li.cn{ L.w)
<br />-l
<br />rmercnDr unds sc.ri,
<br />Irrle: Ovrer
<br />woR(r'I.s coNfl 'FNSAT()N
<br />DECI.AEAIION
<br />I hcrc$y afiirm undcr pcnrlry.rI''rjuryonc ofthc blbwin8 dcclnrtion\:
<br />-l
<br />n,k dd wiu minrDin 0 ccnificilc ol Conscnl l. Sclf lnsurc fo. work$f .\'mpcnsr ion, !s pmvidci ror by sdrion l7fir of lh!
<br />Llbor Codc. lor thc pcdo.tuncc ofihc work ror whicn lhc Fanil h h\!cd
<br />I hxr.r d \illn'ri' ntrr trorkcrr cotr,fcr\rrio, ilr\urxn... r\rcqriturl bt s(r ion 3700 ol lhc tit{tr Qd.. tu thc PcrforroEc ol
<br />i,,n i.\xnmcc clnis lnd Frlicy nunhcr ucncrmir i! tilcn M\ sorlun conmclsrrw €-^r*^
<br />"\OatoX(pS1 g Zr"tY
<br />I .cdny rhtlt ir thc pcrfo!ronrc ,,f rhc sor* f.r shi.h rhis p.irnrl h is\uc(1. I shsll nor.n!n.y 0ny pct\on in iny ntnncr
<br />s rs b bc.r'm sLbrNr io rhc workcs' conDcns0lion lawsofCalinnai . r.d.Arc rhd iil should hccomc srbF.r b rhc
<br />sorkcr( c.mFnsrrion F,v6ions ol Sccln,. 37LrO ol rhc Lutxn Gdc, I \hrll, ionh*ith conll)ly e irh rb* pbuGiotrs
<br />WARNINC: t'rilurc lo rccure w{rkc^ .onDcn{dnnr .ovcrn8c is utrh$tu|. rnd \hnll \ubFj trn cDfloycr lo anninal Fn,ltiN and
<br />civil fitrcs up r. orc hundrcd ihoxsand dolla^ l$loo.fll(jl. i. addirion ro rhc.os ol.oq)cnsition. drtugc\ rl liovidcd nr lhc
<br />Sccrion 1076 ol rhc uhtr Codc, i crc( {nd alkncy.s
<br />,",", 1'\\'\i
<br />I hcrchylilnn uidcr p.ndxyol rrjuly rh lamli.r.ealu.dc.PmvisionoiCh.t c.9(c.marncingwirhscction?um)otDivi\ioo.l
<br />of lhe Busi.cssud Px'fcsiorNCodc. d lnyrrcns is in fulliorcc andcffc.r
<br />b \OZ-\ ld \
<br />o,," I1tt lt
<br />CONSIBUCIIIIN.LINPIIG.dGENII
<br />I hcEby atfirm undcr rEnrhy of p.ijury rhd rhn. G 0 oNlruclion hndins ascncy ror rhc F.noinurcc or rh. {oik tuJ whah fiis I'crnil is
<br />hsued lss .109?. Civ C.).
<br />AITLICANIDECI.AIAIIOT
<br />I Hry afim undcr pcMlr y or pcrjury om of lhc followin8 dslr ioni:
<br />D.nmlirion Pcrmirs'AsiEsros Notifi.arion Fcdcml Rcguhiio.s (Tillc 40. PM6)
<br />-Rcqun
<br />d brrcr orNdifrarion
<br />I ccnifyrhrr rh. fcdorrl rcBuhriotrs rcBardins r\t do\rcnmrlrrc n.rlPplic$lc torhil!r'j.rr
<br />lccnilyrh l hivc rc0d rhis rrirlicrihn di n,rcrlxtrrh.$rvc infonnltion ncotu.r l,!tNlocomtlywilhullCiry,nd county
<br />odindnccsn d St.tc Laws Ehring t, huiUing .onirnrclo[ lnd h.rcby ourlxri& lcPrcscnrrrivcs.rrhis Cily lnd Cou.ryi..nrn uF)nlhc
<br />xhovr rcdri( c t','t).'lyli)r ir\t.r
<br />A|l|)li(,.1 or,\[.nl Si*n$lum Date
<br />P"*il* ."* {p.l.il ( \\^4i^to1^
<br />1 .1\.td
<br />Site-Work
<br />Underoround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Rool Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouqh)
<br />Ceilinos (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rouoh)
<br />l\/leter Release
<br />Rough 7-t7-lk 9.tu761
<br />Service [tl]eter
<br />FINAL *-Ll-t4 r i*n -,t -)'iz )
<br />Notes, Remarks, Etc .ulj
<br />ELECTRICAL-INSPECTOR RECORD
<br />Transformers
<br />ba5-7-
<br />t nd.is Addrc$
<br />-
<br />tt
<br />I
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