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BUTLDTNG- tft specroR REcoRD <br />DATE ID/SIG.COMMENTS - Omr-SuitdG, OcLntion <br />I k{cby rffirm uds pillty of psjury rlu! I m orcmpt fom tho Contncon' Lim! t rw for tho following rucn (147031.5 Eurim; <br />rod proforion codo): Ary city or county which rc4uto r pamit !o oBtruct, rltq, improvq_domolirh or roprir uy ruuotug pior r itr <br />f.i-i.i .fr" i.qrtrl oJ.ppii-nt for oi.r, pcmit 6 {ilc r ii3ncd rtrtmrt thrt h. or thc ir llccood pununt to tlo provlrlou of thc <br />Conhclor'r Licilcd trw-(bhrpra e, Commcncing with Srction TOOO of Divition 3 of th! Bultr{ rnd ProfstioLt CodG) or t}8 ho ot <br />,i" ir iorpt t.r.tom rna i* urrir for rlp rllogcd o<cmption .Any vlolrtion of Sction 7031.5 by my rpplisnt for r pmit rubicctt tho <br />rppliont to r civil pculry of not mr? th.n llvo hundrcd dolhn ($500)' <br />I. r os6 of lltc Dropony, or my opbyu with wrga u thoir rolo compcutioq will do tlE mrk rnd rhc ttrucruo L not intodcd <br />o-, JirJfoi r[ t S*.zOg, il.initr .ia Profo$iou Codc Tho Co!tsrc,tor'r Li6r. Lrw dos f,ol rPfly to u ow of tho propcty <br />who buitdr or inprova tlroq md who doa ruch wrk hiruolf or hmolf or throuSh hir or h.J-om Gmployc.+ providcd thrt rucl <br />irpioro.dr rd-t htodcd orofisod ford.. I4 bowvlr, thc builditrl ot inPlown.ot it told withi! ono yan of onplotioq thc <br />omc-Euildc will hrw tho burdm of provhg thl hr or rha mt build or imProrc for tho pupo$ of nlc), <br />l. u oms of ilr prcpaty, m duivoly 6nt[ding wlh lieuGd ooatrctorr !o @illru€a tho Projrd ( Sc 704'1, Buhq rnd <br />FEioion Codc: Ttro'Coirtrrirorr Uccm Lw ds mt rpply to u ow of prcpaty wbo buildr c improu tlcao . rrd who <br />@ntrrdr for rucb proj(ar with r Contnad(t) licanod prmat o tlo Cornaor'r Lic.s bw )' <br />& P.C for thi rurotI m axopt utdcr Sstiotr <br />Dr&: <br />WORKEf,,S COMPf'{SATION DTCI,/\N TION <br />t bscby rftum unds Puhy of Psjury om of tho followlag dcchruiou: <br />IhrwUrdwilluistrinrCqtfiqr.ofcoil.ottosdf.Iflmformrtcr'onrposrion,u pmltodforbyS*tio!3700ofth6 <br />trbor Coac for t!. pdormncc of thc mrk for wtri:b th. pcmit ir imod' <br />I h.vc ud will minttin worlsr' omp€rrdion imnnc.t u rcquircd by Scalon 3700 of th! L.bot CodG, for tho gcrformnco of tho <br />Grk for whish thir psnh b i$ucd. My rctko' caogoution irume crnior rnd policy numbc uo: <br />Policy <br />dollen (t100) or los)(Thu rction Dot bG onplcrd if lhr <br />I 6tify lhrt in th3 psformnc of thc uork for whi<t rhir pcrnit- <br />b*rmc rubjcc to thc mrko ' conpcutis hm of Cdifomi+ rad <br />ir lrucd, I in rny nrnaa <br />tho rcrkd' <br />lorto <br />t8@ <br />6mPArrtioI of Sqsdon <br />/r. <br />3700 oftho L:bor Cod., I <br />WABNING: Friturolo ffi mrlld'@Blpfltion @vc.r8o ir ulrwful, <br />(t100,000).in rddhiotr to th. ott of <br />tha Lrbor Codq htqet rtd .tlonEy't f6. <br />@ <br />I hqcby rfiirm unds pcolty of pcjury thi t m tienrca udc Arovi.bo of Chrptr 9 (@m.ncing wilh S4tion 7000) of Divibn 3 of <br />tho Burigr ud Proft$ior Codg rnd my lise it h full fore rtd .ficcr <br />Liouc <br />D.tq q <br />I hqoby rtrm unds pcrhy of paiury thrt thqc t rScncy pcrfomno of tlr worh for which thir pamh ir <br />, Civ. C.). <br />L.nd6'r Addt{: <br />AIII.ICANIII.^PICIdSAIIAN <br />Dmlitba PmiE-tubcrto Notifrcrlioa Fodol Rogulrtioor Oitb 40, Prn 6) <br />_ Rcquircd Lns of Notifiotiotr <br />-I <br />cstify $ut Utr fodol rcglhtbB rc$rdirg ubdrd rffil so notryPlirbh to thir proFa <br />md rd! OLt th6 rbow iaformrtion ir on!d, I 1816 to @mply with rll City rtd Couty <br />6umaio[ nd lEoby ruttorizo roproonetiw of thir City rrd Couty !o 6rs uPon tho <br />rbovc mstiomd propGrty <br />Appliqnt or r86t tig. <br />Pqmittc Emo (print): <br />t/,o /," <br />Set Backs <br />Forms/Steel/Holdowns <br />on Pads <br />FER Ground <br />SLAB Floor <br />SubfloorA/enulnsul. <br />Roof Sheathing <br />Shear il <br />lnsulation/EnergY <br />Drywall <br />Ext./lnt.Lath <br />Brown Coat <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final <br />Engineer Final Report <br />Flood Zone Certif.t\4" l&{r /) <br />I tffiru IlY 7-wh{r\4tb F\r7 +fl91J r/hLLnD ) <br />of Occu <br />Notes, Remarks, Etc. <br />Framing <br />Masonry