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APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underqround
<br />Pole Bases
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Signs (monument)
<br />Life Salety /Low Volta
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Buildinq
<br />Bonding / Groundinq / UFER
<br />Transformers
<br />Torqueing
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilings (Hard & Soff it Rouqh
<br />Ceilinqs (T-Bar Rouoh)/..,)
<br />Meter Release z-12-tg h -w-)t)
<br />Rouqh t-\- t9 .-l)"9d ,nd')
<br />Service Meter 7-lz-tv v.w-m
<br />FINAL tr9-/tr Y,ttlitl
<br />Notes, Remarks, Etc.
<br />OWNER BUTLDER DELCARAIIIJN
<br />I hcicby aftirm undcr pcnlhy oI Frjury lhll I 0m cxcnpt imm lhc ConlrrctoF l.i.en\c ljw lor rhc ,ollosinE ra$n (s.c 7011.5
<br />Businc$ lnn Pnfcsion Codc): Aiy Ciry .r Counry *fiich rcluirc. ! pcdrir k, condruct. alr$, if,pmvc, dcmolish or rcN" My
<br />idcrrrc. IlIitrb irs n\rnrc. dso rcquims rhc af,plicrnr fu \rchFmir b lllc!siSn d (dcmnt rhm hc or shc ! lienrd lunu t
<br />ro lhc pnvisi,tr$ ol lhc Conlrlcru s l,iccns.d lju (Chaptc, 9. Comntmi'rs wirh sc.rbn 7ffn .r DivNi.n I ol thc Businc$ ctrd
<br />Pturc\(nrnsCi cl.r'hurt orchc ir cx.rfl rh.rcrrom,nd
<br />'hc
<br />b,rn ror (hc alkBcd crcmtlion AnyviolarionolS(ri,o70ll5bya.,
<br />lmlicln 'or a pennil suhjalsrhe aprliclnr to acivilpcnallyofml nD.e than fivc nundrd doll8($500).
<br />l. ,r owmr oirlr p6pcny, or my cmployccs rirh wagcs as $cL q,lc m,q.nsar ion. qill do lh. wtrk !.d thc srrut@ i\ n
<br />intcndcd or oilcrcd for slc (S( 7044, Busine$ lnd Pmlcssiotrs Cdc Thc Cod.acrois Liccn* ljw dds nor rpllyro rnowmr or
<br />rh. I,spcny who hoikh.r irf,(,h\ rlE6.. sd who d,rcs \eh *oil hims.lfor hfi€lfor rhmu8h hn orhn own cnrployccs.
<br />provid.d rha! such iqrowmnrs m mr inr.Ddd or off.!.d f(r elc. ll, horcvcr, rh. bdild,nS or iq"orcnr kbtwnhinorc)ro
<br />ofc.nlllcriDtr rhe Oskr Bliklcr willhaw lhc bndcn ot pmviry lhnr hc or shc ilid mr build or irprcw $c pmFny lor x Furpo$ol
<br />l. *o*krofrhc Jm!.ny, amcx.lxsiwlyconk&tin8 *th li.cn{d .ont.cr o rs ro onnnd ltr pnlcd (Scc. ?(}+,1. Bu\iN$
<br />a'rl h.ic$bn Codc Thc Coorrlcrof s t,iccnsc l,aw does nor opply lo !n osNr or proFny *ho brild* or inrtow. rhcrsn,
<br />and eho conh.rs ror such pmjcts virh a Co mdo(s) li.nscd tusu.nt ro rhc (.onlmcro^ l-iccnc tiul
<br />I mrcrcnln uMcr S..rion ,B.&PC lor this rcason
<br />u.r",6Ll -lo ?,or! o*-,
<br />DICI,IISAIION
<br />I h.r.by rrTiribrndcr pcnalrtoln rjurronc of lhc l'ollouirrS d&lffr'io.s:
<br />-lh0vcandwillrmint0inaCcnificilcofConscntioSclf.lnsurclorwolkc$compc.sarion-asprovidcdforhrsccrbnlT0oofrh.Lrhr Codc. tu thc lcrfornDncc of thc mrl for whichthc pdnir is asucd.
<br />_lh cindwillmon rinqortcn compcnslrhn insu.rncc. as rcquned hySccrionlrTO(,ofrt. tjhorGd.. ft, rh. FlfonMk-.c or
<br />thc work ioi*hichlhk p.nnil is issucd MyworkcG comp.nsnlion iNUr{Ec clrdcr d polic, nlmhcr ac
<br />I ccniiyrhrr in rhc Frtormrnce ol rhc worl lor which rhi\ pcrmil t t\md. I \hrll nor dnrpby rny l.Nr ir rny m rnet
<br />s r\b lr{o'm sub)..r ro rhc wo*crl comlinsdi{[ liws Dl Cnlifdni.. lRla8rcc rhd il'l {houin bcronr a6jsr h rtr
<br />woikc^ .o fcn\di{)n pbviatutrs oi Scdn n l?00 ol lhr Lrhtr C.d.. t shrll. lon hsilh cnmply wiln rhl){ pmvntDr
<br />WARNINC Failu.c ro {curc workcr\'ronTrn\dn'n.oecnac ii unh!tuI. n d $ill \uhj(l rtr cnpbycr ri, ctimiml pcullics and
<br />cilil fincs op b orc hundrcd rhou\ahd dullDr\ ($1fir.o(X), i'r rddirioi o rhc.o{ .f compcns.rion, donm8cs os ptr,vidcd lor rhc
<br />Serion 1076oarhc liboi Cod., inrcr.{ ond rilorfty s fMi
<br />, 0q -io - )o(Q nrrr-*,
<br />DECI.ASAIION
<br />I hcrcby nirr'n undcr p.nolry nf lcrjury rhol I onr liccn$d utrd.r pmvkio. ofChIPtr 9(com
<br />or rh. Busin.* rnd Ptufcssions Codc. anl nry li.ctrF is d fuu foEc rrrl cliccl
<br />C(}NS-IRUCTI(IN I FNDING AGTNCI
<br />I hcEby olfiirnundcr pcnallyof lcrJury that rnm k r.otrsrruclion lcndins arety for rlt pofurl1rm. orrhc wort aor whichlhis !€rmit is
<br />issu.d (Se :1097, Civ. C ).
<br />APPLICANT DF(]I ARATI(IN
<br />I M,y,,Im xndcr pcnrlry or prrjxry onc ollhc rollowin8 dNlrnrions:
<br />De n lirh n Pc tril! A\l,csros Norin.nr ion Fcdcrrl R.EUld idF (l irld l(). Pd6 r
<br />_R.quirrd l,(cr ot N.rifi .arion
<br />l.cdilirh.r ifu rcdcrrlrc8ul,riotrsE$trnnrr $bcstos r.nbul urc nolnpplicablc l. rhis pn+cr
<br />-l
<br />ccrriiyrh lh!!c rcrd rhh0plicrrn,nud (arcrhar rhc ahovc inlbnnlrt'n nr.nccr l dgrm ro omply wirh all Cily otrd Couoly
<br />odinamcs,.d St.rc Uws rcLtins k, buiklins cnn(oction. and ncrchy.urh.rir rcrrcscnrarilcr orrhi. cir, and cou.iylo ctrrs ul)on lhc
<br />hrr nf,ri(nrJ p()lcny nr i
<br />Appliunt or AA$lSiANlur.*" 64- lo ? ^lt
<br />I
<br />ELECTRICAL.INSPECTOR RECORD
<br />Under Slab / Floor
<br />Liccnsc Cliss:-l,iccnrc N0oltr:
<br />-
<br />D.re ( onrrocror.
<br />tfn.ttr'. 4n,t,...
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