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SITE-WORK DATE IDiSIG.COMMENTS
<br />L as osncr .r rhr r(,ltny, or ,ny o 'tl,,yr.s wirh w0scs 0r rhcn bh compcnslrion. will do rhc *ort ud thc ntu1m is tor
<br />inrcndcd o! ottcrcd lor elc lse.?04-1. Ilusincss nnd Pmr.s\n,n\ C,xlc: l-hc Contrckr's Liccnsc l-aw docs.orapplt o dn onn$of
<br />rhc r'op.ny who huills or impn,vcs rhcmn. .frl who des suh soll hnnrll or hoscll or rl$u8h his or hcr own cDrp()yccs,
<br />trolidcd rhlt \uch impnrvcrmnrs arc *n idlnLd or oftrc{l fir slc lI howckr. rl[ ti,ildirg or i'nprncmd h dd Nirhi', .trc ]ur
<br />oicon{'lction, rlt Oqkr auikcr *ill hr{ rtr burdchofpmvin! rhsr hc o. shc did nor 6Dill or i'ryro\ rhc lrepcny tn rhc puqD* ol
<br />l- a\.sncrofrhc prop.ny. aarcxclNivclyconr.dirs wirh li..nscd .rtrrNIors to construd d. pmlc.l (S( 704,1. BNinc\\
<br />ond Boto$btr Codc: Thc C.nkactr'r Litcn\e l-!w doc\ nol lpfly ro on ownq olnropcny wno build\ or inpolcs rhc.con.
<br />ond who conlmch ior such,mirrr snh . Coda.rtrG) li..i\cd pu^xnr hrhcCoftr.rtr * t-iccn* Ijw)
<br />-l
<br />a crcnrplundcr Scclio
<br />,IIOAtrEAT:IjOMIENSAIIONIl[rtrt&r]p!
<br />I hcrbyrltu ru d.rp.lrlryof p.rjuryoncof rtutull,rwirgdc.lndion\:
<br />I hdvc uid willnlinuin u Ccniicnrc olConscnr ro Sclf lnsurc lor wolksi ompcneriur. as rmlidcd lor t y Sccrn,n lT0Oolrh.
<br />l-,hor Co!c. i.. rhc I).rfonMmc ollnc wo* ,or *hi.h rhc pcrnil is i$rcd.
<br />_lhrlcind{illmoinrrinqorkcrscom|cm.tnrir1sufurf,c.a\rcqrnddhtSc.ti.rlT(Dofrhcl-b.rC(d..forrh.l).rfonr!rccof
<br />rhc *1trk lhr $hi.h this |)cmrn is nsucl M y sort.s cu rFn\arn,n insurrn.c .micr drd Fni.t nnrnb.r &cl
<br />PolicyNun$cr Expncs
<br />I ccnily rhtrr in rhc pcriorroncc ofrhc work aor Nhich rhn lrilnir is ksucd. I rhill nor cnlloy ony pcnon in lny manmr
<br />s $ ro b.comc subjer r. rl'. *orkcr{ c.nl.nsd ion h*s of Cllitumil and 4rc rhtrr il I \h,uld hcc.m \ubjcd b rri
<br />wortcn.ontcnsrtmnpn,visionrofSdtbn.lTmoflhcLitnrCodc.lshrll.f{rjh{ithconplywirhrto{pmlisbns
<br />IVARNINC Failurc lo ccurc workc6' con{'€trsoli,,n covcEr. is unl.stul. .trd shrll sDbj..r an c"lPlorr Io ciDirrl rMlrics ind
<br />n' orc hunnrcd thousrrd dollnrs ($loo.r[D), ir dddiri(,n lo rhc co{ ofco i.n. drnr8cs rs Ircvirlsl lor rhc
<br />:::,T,YTi
<br />DECI.AMIDN
<br />I hcEhy lfirn rndcr p.Mllyofpcrjuryrhal I m l,mtred undcr r{,vi\ion orCh,fl$ 9 (enrmnciig eilh sc.rion 7000) oiDivision 3
<br />ol rh. BusiR$ dd Pbrcssiona C..L. arxl m, liccosc is in tirll folcc md eficcl
<br />t8 t
<br />C(}NSTRUCTI(}N I FNNINC A(iT'N(:Y
<br />I h.tuby rrfiln undcr Itnllry ol Frju.y nnr rhcrc isaconsrruclio lcDdi.!qcncy r'or rhc r.rinruncc ofrhc,ork lor {hi.b rhis Frnril is
<br />nrkd (Scc.109r. Civ C ).
<br />AEEUIANLDEII.AAAIION
<br />ln E$y afiim undcr pen0lry ol!.rjury orc of rhc rollowin8 dNLrari..sl
<br />Dcmolilion Pcirnirs.Asb.sos Nol,fi.dio, rcdfirl Rcgxlnrions lTirlc 40. Pd6)
<br />-Rcquie'd
<br />trllcr ol Noilf,,rn,r
<br />I ccnilirhd rhc ltdcrrl rcBUld i,rN agnllnE (sh.{osr.trFvrldc tror.p|lic$lc k, rhh protrcr
<br />-lccnilyrhdIlNcrc.
<br />rhirapplic.hotr ndsrr.rhdrrhc hrc i'irornEr n i\.odc.r.I a8rLrro.o fly *irfi nll Ciry aM Counry
<br />o inamc\ and sr0rc liws rclariq lo huildins c.Nrucri,rn. iftlhcrcbyaurhorizc rcrcsctrhrilcs olrnt Cil, and Counly ro cnlcr upon rhc
<br />ati)vc nEnti,,ncd pn,D.n, 6r iNlncrion
<br />Arpli(rnl or ,\|rnl si,rnakrn
<br />Pem rftmne(pdnr): ,/+J rc^)&t/\z<
<br />af ,'f ,'
<br />Sel Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />Sublloor/VenVl nsulation
<br />Ro of Sheathing 4l?,61d1;,N",et//2 ,)
<br />Shear Wall l UI
<br />Framing
<br />lnsulation/Ener gv
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lt4aso n ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Beq
<br />Deputy Final Report
<br />Engineer Final Report
<br />I
<br />FINAL ,/2/azh ".-M-,;)
<br />Certif icate of Occu pancy
<br />Notes Remarks Etc
<br />BUILDING. INSPECTOR RECORD
<br />Erection Pads
<br />SLAB Floor
<br />Drywall
<br />Flood Zone Certif .
<br />OWNER I}UILDEN DELCARATION
<br />I hcrchy,ttum undn,cn.hy r'r pcrjury rhir I un cichpr aro rhc Conrrrrnc Li.cnsc lj* lor rhc toll,,siiE rd.s,r (sc.70.rl5
<br />Bu\inc$ rnd Prnfcssion Codc) Any Cny or Connry which rcquncu Fnhn b .on(ncr. dlrd, im {,vd. d.trDli\h or q),L any
<br />dtucrur., prt,r. n\ nsusncc- olso requnesrhe aplicr lbr such trilnirto lilca si8.cd statcnrtrl thor h.or shc is liccnscd punua
<br />b lhe provnions nfll* Contr0clor'i Liccn$d bw (Chnplcr 9. ct,m FminS sirh Sccrn{ 7{Xx) of Divisb. ] .f rhc Busincs and
<br />Pml.\\t,n\C{xlc)o.ihlr hcorrhc is€xcmrlrhcEliomaDd rh. b.sis lor lhcallc8 ncx.mDlion. AnyviohlionofS.dionT0ll.5l,yrny
<br />rpllic0trl for l,rnnir iubjcch lhc appli..nr b a.i!ilpcnslrrornor morc rnrn fivc hundrcddolh ($5001
<br />B &PC turrhis'crn .
<br />I
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