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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER AUILDER DEL(ARATION I hcr.hy amfr undd p.nrlry of pdrury lhal I m.rmpl from thc ContadoB-Li..e IjN for rh. follolvins raen (s( 70115 Busin6s and ProfNion Codc) Any Cily or Con y shich r.quts t Fmil lo coNlrud. alr(. ifrprova dmolhh or rctâ‚¬t ur. structuc. prhrlo s isud.., also &qun6 rh. appli.a fo, soch p.mil to lilc a sisn.d narmor rhar hc or shc i.s licoE.d p!6umr u rh. piovisions oflh. Contracloas l-i.ds.d Iis (chap( 9. (_om.n(ins Nilh S.clion 7000 oaDivision I ofth. Btrsin6s atd Itofcssons Codc)or rhrl h.or sh. ir.r.mpl rhcEfron md lh. bsis lor thc allcs.d .:dprion anyviolarionols.dionT0:ll5 b) an! ,mlicad ln a pdnn subjcc rhe applic.nl to a ci! il p.nahy o I nol morc rhm liv. hun&.d dolltrs (S5C0) I. as 0*16 orlhe l()psl), ornt.nplor6 wnh saBB s rn.n Fl. comlEdsartu.. {ill do rh. $o ard th. nn{ru. i nur imd.ldt.rolIa.daorsl.(Sa7O,l4.trusinGsddPrer6sionsC.n.:Th.cont.dorsLicmcl:$do6nolamlrkrMo$nsof rhc Impsly_ *ho hoildi or mprov6 $6atr ed sho do6 such troi hims.ltor h6.laor thrculh his or hE os0.n,pk yd. providcd lh.l srch imprcrooc e nol nrd&dicory)ldion, rh. o*n6 Blildr will havc thc hrdd of prolins lhd hc or sh. did mt tuild or inFrcvc lhc I'lpdy lor lh. Al'Ioe of l. as o$ns ollhc frol'tny. d. c:clusn .ly conta.tin8 u irh licmsd conlndoN t. connMi rh. Fttjd (Sd ?Lr{4. Irus'n6s dd hfeiirnCod.: Th.contacto.s Liccns. kw do6nol.pplyto an01 6.lfrupdt$ho burldsor im!'o\cs rhdmn. and \vho conrra.ls fo! such Foj.ds N h a Contado(s) li.ns.d prsr@r ro lh. ( onlraclois Lr.6. l-dw) I dn.xcmpl undd Sâ‚¬clion ?OECIAIAIII)} I hcrcby aflirm unds lEnalry of ldlury onc of rh. aollos ine dcleal ions: I hi\. Md $ill mainr.in a Cqlilic.tc of Consdr ro scll lnsui. for work6 composrion. d Fovid.d for b! Sdion 1700 of thc libor Cod., for rh. tEforrucc of lh. {o for which th. pm n issu.d. lh.rc ond *illmainrain sork6 .onp.nsarion imtrmn... s r.quircdbySertun3TO0olrh.ljb.r(od..forthcp6romMc.oi rhc *o!k ror Nhrch thN p@ir G issu.d My $ 0116' compoel io. iNurancc cmr md pollct numbd ac: I.dilyrhar in rh. psfoirnan.eoflhc rort for which lhis porir ,s issu.d, I shallnol .,nplor" any p6on i. an!,nMn( $ 6robecornc bjal lo rhc sort6 .ompasdbn 1a\6 ofcalifomia. Mdascthar irI sh.uld t*.ofrc $bidl lolhe *orkss' mDpo,sarion pnvisbN ol Sd ioh 1700 of th. titi.r (-od.. I shnll. fonh*lh .omply wirh rhoe pm\ isiotrs wARNlNc: Failur. ro Fuc Lcorkm compasnion cov6ag. is unlaqful, a shall suhid @ploye to riminal lEnaki.s and .iril nn.s op lo o.. hundrâ‚¬d lhouend dolld ($l 000). in addirioo l. th. cosl of compâ‚¬Barion. dm.8e 0s pro\ rded. fot lhe sdion 1076 0flh. Lattr codc. mrs6l and at. u|! L!!!.1!11^ I h6.hy amrn unds po.lryolpdjuryrhar I dn licfiscd unds I'o\6ion olChaprd s (cornocins *'ilh S<rion 7000) ofDivision l ol th. ltusinde and PofNroB Cod.. dd my licds. is in ftrll forcc d .tTEi CONSTR!CTTON I.trNDING ACENCY I hd.by dflim undq poslry o f p.rjury lhar !ho. s t coBrtudion lmdin! as6cy for lh. pdfoilmc. of lh. *ort for \hich rhlq pdnn i! issu.d {sr 1097, civ c.) arfl!(a.[lul(u$auor I hd.t'y alInn undd lmah, o I p.rju.y one of lh. lollo*rs dEldai ions Dcm.lnmn P.nnirs sb.sros Nolificaiion f.d60l Rqulalio.s ('r' Ic40, Pn6) R.!ut.d L.nd of Nolifi cslion I cqlily lhal lhâ‚¬ r.dqal r.sulari.E tredinu sb.sros ronoElarc ool lpplicahlc (r rhis rrojdr o mn,plt Nirh rll( iry.nd Counly lhtC f dd(o nrrro016trponrh. lcdriiy rhlr I hav. r.ad rhi. applicalion ud stolcthat lh. abovc inromdtn,h t cond I asrel ordind.6 and Srar. tlqs rcLrin* ro blildins consrodn,4 md hd.by adhoriz rcai$lalir6 oI ,h1. mm,'o..d rr,pdr ror,?txr,6n pu'pos - .. :,:::::,:::'"y<r'--'R -,,81a4 Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subfloor/VenUl nsulation Roof Sheathing Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif t --) FINAL /r'/t '//{ *x t/t ,/ Certificate of Occu an Notes, Remarks, Etc. T-Bar