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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUI LDER DEt,('ARATION <br />I hocby rflirm utuld FDlty oirojury rhar I m cx.dfl nDm rhc Conha.roE Licm li\r lor rh. lollorinr r.etr (Ss 701r.5 <br />alsin6s .nd Prol6sion Cod.)r Ant City or Coudy $hich r.qun6 o p6mil lo conslnrct. alt6. improve, dsnolish or tpair dy <br />srtudrq rior lo irs isuuc.. sl$ r.quiB rh€ qlpli.d for su.h !.mil ro 6lc a sisned statmml lhal h€ or shc 6 li.ors.d poNafl <br />ro rhc provisions ofthc Conrdcrois t,i.c.*d L.rv ((haplr 9. Co'n,ncn ing $nh s.dion 7000 of Divisioo I ollhc Rusins &d <br />Prefsi.ns (ode)orrnar h.orsnc b.r.nDr tho.lrornandrh.hsk aorlh.allcS.d cro.plion AnyvioldionofsdhnT0.ll5byey <br />applica for a pmil subjdl3 th. applic.nl lo rcivilp.nrhyofnor morelhe liv. hundr.d doll.6 ($500]. <br />I. 6 owncrollh.I,oFry. or my dnployB silh salsa lhcir sl. comp€Mlion. rvilldo Ihc trork and rhe ntodu. G ml <br />intd(H o, orr.d for slc(56.7044. Ausin6 rnd holsioN Codc: Th. Coitadr\ Li.@ Lr$ do6 nor.ppltro.tr 0\16 oa <br />E pNp.dy who h & or imprcvB $60., aftl who do6 such *o,{ hins.llor hdsclf orlhrr]u'8h his or her o\yn cmployeB. <br />prolid.d thd such inpdcn nt e nor i ad.d .r ollddi tr)r sL ll howdd. rhe hriL.liru or nnprovdn€rn is $kl *irhi'r otr€ yw <br />ofcomplelioo, thc OM6 Srildd will ha\r tlE hrr&n of poi.s lhd hc or sh. dd nol build 6r iqrcrc rh. prrFry for fi. purpoF ol <br />El. * o" n.. o r rr,. p-p<y. - Bclstr ely (nnra(r! s'ilh liccs.d co radon tu .oBrtu( rh. prujd (s(. 70.1.1. Busins <br />and PJlcssi.h Cod.r Th. conta.rois Lic.ns. Law dos nor apply'o an oNn6 oaprop€ny (ho buil& o. nnprove rhaon. <br />a.d *ho co !a.ts lor such projc$ $ilh a Co r.cl.(s) liccnscd pusodr totn. (bnlrnclois Licen* Lav) <br />_l@cicmpru n S(l'o._ ,B &PC I^r rhi{ r.asaa ,- ! <br />,.," . t[lr-UlaolL -".,,). "Xryo Z ddl!oatrEa5i!r!t[!.la.Ua! |-DE(IAIAIII'! I <br />I hdcby amrm ufldq p.nllly ol lqjury on€ oflhc followins d<ldalio6: <br />I halc d Nillmainrain a c6lific0t.otConscnt lo Self-lnsurc tor Norksi conDcnsalioi, as poided Lrbtsdior 1700of lh. <br />Lrbor Co!c, fo. rh. p6fom&cc olthc worl lor *hich rhc pamir i! iisucd <br />I h.vc af,d *ill mainl.in *ork6 comp€ns.t ion isu,onc.. s .eqtrned by Sd tuo 1700 ol rh€ lrhor Cod.. tor the lB nrmec. of <br />Itc work lor whi.h lhie p6mil is isucd My workdi onrp$srion insuBncc cri6 dd poli.y numbd &.: <br />E\ cenr$ rnar in ltrc psromwcc olthc \orl lor trhi(h $is psnril is issued, I shallnor dnpl.y a.r t6on in otry mntrre! <br />s 6to beod. subjsr lo rhc $0116 .omposarion la$ ofC6lifomia..nd +E thit ifI snouH bccor.. subjal lo lh. <br />(0r[6.o,nprsarionpmvtionsofsdion:J700ofih.Lah.rcod.,I3haU.fonhwithcomplywill,lh.spnvnions. <br />ltAliNlNC F ilur. to Kuc "orkm ompds.lion covelas. is unla*ful. ed shdll subjd d dplo}cr ro oihiml tEali6 md <br />civil fin6 up to on. hnndrcd lhouend dolltrs ($100.000). in addilion lo th€ cosl ofcofrp€.strion, danaBs as Oolided aor lh. <br />s(rion r0ro ofrhe L.bor Codc. inrsqi <br />,,,,", , lo lzil 2ol( <br />DECI,AAAII!]ts <br />I n@by anim undq poally of pqjury lhar I m licdsd u.d.r a,ovision olChaprd I (co,nmncing snh Se.liotr 70Ct)olDirisior l <br />or lh. Bnsin6s ed ProadioN Code, md my lic.e n in tull 4o... dd .rd. <br />qaNlrauc.ullrL[rDlNclcENcr <br />I h.Eby amm und6 pcrahy of psrury lhal lh6. b a cotrrruclioo Lndins asdcy for rh. poaomdc. 6a$. \ ort for \rhich lhis pq.n b <br />isstr.d (Sd. 109?. Civ. C.). <br />atauc .NfD[qdaalt()N <br />Ihaebyamnn undcr pcnally ofpqjuryonc olthc lollosins decl.ralions: <br />D.molnio. P.mtu Asb<sros Norifi.arion F.ddal R.guhbns (lnk40, Fan6) <br />Requircd L.ucr olNolinc.liotr <br />I cdin rhd rhc f.ddalraLlarioN Rddin( 6besro, rerno\il .ro!appl'c.hlcror\irrajd..1{ <br />tsI (d'fy !ha' I h!!c rsd rhB EDI'c,r'.n dJ !a'c'h,rrh. ahov. inlonn.rnrn i.oftdt IaSrd(ocomtlywirhsllCilya.d(ouly <br />orlinaoc6 ed Sralc rrws Elatinr ro blildins co.srtodioa &d h6.by auhorn.r.pr6nl.liva ofrnis ( ily.nd Counl, to sl6 upon th.. lo)-L6lLQil <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loorfuenUlnsulation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />ln s u lation/Energ y <br />D rywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />l <br />FINAL 8/74ry /M4 ) <br />Certificate of Occu nc L <br />Notes Remarks <br />- <br />Set Backs <br />, Etc. <br />aboLc nrelr(.n.d pmndy f.r iNedon p5:)F c -l t <br />Appricnnr orAEm, siqnr,ure >1 J'//{\- C^ dodlf\ <br />ronrrenrnerprino, !( [.y4f,]q$f ' <br />-------T------ <br />T------