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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE IDiSIG.COMMENTS OWNOI BUILDER DELCARATION <br />I h.Eby amd undd !.nalt, oapdjory thal I @ .xc6pr from Ihc aof,lradoE LiceN Law for lh. follo*ina r.e. (Sd 7011.5 <br />BBi.6s .nd Prolsion codc) Any City or Counly $hich r.!ut6 a pqnit lo con$tucl, 3110. imPro\c d.molish or tcpot uy <br />srudu.. p.Dr to ils isuuce ale re{utr6 lhc applictut for such lcmn ro nb a sien.d st.tmat lhal h. or sh. is lictudi ,u6uarn <br />io rhe provisions ofrh. Co.rrrcroas Licdscd tiv (Chapl6 9. CoftmencinB virh S.crion 7OO0 oaDirision I ofrh. Dusindi aid <br />Pofsions Code) o! thar hc or she is .rcmpl thdcEom ud rhc bsis lor th. allca.{ crmplio. Anyviolaliotrofs.dion 70ll 5 byany <br />appli.ant for . p.mn subjcrs rh. applicdl ro acivilpcnahyofnot eo( rne 6v. hu.dr.d dollas ($500) <br />l. s omr oarh. pmp6ry. or my flployG wilh wag6 s thct sl€ (e!€tualio.. will & $c wok and fic $ucl@ is nol <br />inlo{l€d or o,Is.d aor elc (Sa.?044. Busin6s dd Prci*sioB Cod.: Th. Conlftdols Lkre L.s doB nol apply lo & oMo o a <br />lhc proFty *ho hil(t3 o. nnpo!6 tlE6., ed who dG such m* nimkll or h*llor lhrcush his ot hd oM.nploy6, <br />p.ovidcd rhd such imFovdnots @ ml htad.d ot olIdcd aor st . li howd6. lhc buildDs or i,qftva&nl i5 $ld wilhin on. ya <br />ofco'nplclion.lhc Ovnd B{ihs will haw tn bu&f, oapmvins lhd h. or elr. dA f,ol hild o! improw fi€ Fopsly tur rh.,\trF* of <br />I. 6 ownd oalh. ,ropsly, M dclBiv.ly contadinB wnh licm.d contnclots lo coniruct lh. Fot.(1 (s.. 7044, ltcins <br />0 hoftssir Codc: IlE Conlrerois Li.cnsc tlw do6 nor apply ro d ownd ofpropdi, who builde or improvs th6on. <br />dd who coir&ls hr s!.h proj.ili wilh . Com6do(, lt..$d pu6mt lo lh. ContBclois Lk6e La*J <br />I d cr@pr sd6 Sario B & P.(.lo.rhis r€Mn. <br />]{AAf,DIS:C9MC!!SATAN <br />DECIABAIIO! <br />t hdcby ammundd pdaltyofpajuryonc oflhe following d<ldarioB <br />- -.1 havc s'd will mi.tain , Cslitclrc oacoe.' ro S.l!lNu. lor {or(6 conpdarion. a pmvid.d lor by Selion 1700 or lhc <br />Labor Codc aor lhc p6fomoc. o hhc wort lor vhich lhc pqmit G bucd. <br />'(t ru'eua *rttmamrarn *"116' odpccrr'on ,6ut(c. 6 r.qu@d b) <br />rhNlrl lo, qhich lhB pfnd s *scd M) *o 16'ompn&ron rBuffi. <br />.*. tS|.^\a Focrd <br />Sdr ioD 1700 of rh. Labor Cod., for lhc pdfomdc. of <br />cffiid and policy numba m: <br />--Lc-,() - t-\-7 <br />I cdiryrfiat inlh.Fao@nccofrh. $ort ao. {hich rhis pemn is issu.d. I shallnot mploy any pffi! in..y ndn.r <br />$ a to ban,rc subjd to th. wort6' .omp.roal ion laws of Califomia. aid as@ lhat if I should b..om. 3ubjd lo thc <br />ruorkG compeetion pmrisiom ofSeltrn 1700 oflh€ l,bor Cod..I.lull. aodh*nh compl, {ithrhosepmvisions <br />wARltlNGr railu. ro suc Noik6 m'npqsflrion covsas€ is uola*tu|. d shill suhjdr m onployd ro aininal p€mhi6 Md <br />cilil fins xp to onc hundrcd liou$nd dollm ($100,000), in additioo lo lh. co oacomp.ns ion. dma36 6 p,ovided for.th. <br />S6rio.1076 olttc kbor Code. i.r66l ud alroruy slG <br />L-.'. c C.,l .r <br />I hftby amm undd pcnalry o f pdjury $ar Ln [cmsl u.dd Fovisior of Chapt6 9 (tmndcinS wnh sa]lioo 7000) of Dirision ] <br />of rhc Busins d Ptuf6siore Cod., a.d dy Iic@ is i, tull fo,cc and.tfer <br />l+1 CL Sr[0s ( <br />5l-\ iruL <br />calgEuqlloNl[lDlNciclNcY <br />I hdcby afiim undd pcnalty oa pdt!ry rhd thdc b a oBrtuclion L.diD8 lgdcy lor lnc Ffoi,@cc of th. sotk aor wnict lhis pcrmil is <br />i$u€d (S(.1097. Civ. C ). <br />ATTI,ICANLDECTdAAI]O! <br />I hclny afim undd poally ol pgjury otc of lhc lollowins ddlelionr: <br />D€mohion PdniteAsb.stos Nolificalion F.d6al R.tulations ( l nE 40, Pa,l6) <br />R.!un.d L.lls of NotificBlion <br />I co1i8 lhal thc fcddal rcgularioB r.gdding sberos ronolal trc nor applicabl€ lo lhis proiccl <br />I.dirytlh I ha!. @d rhis oppl tr dd slat. that tn€ abov€ inlonnation i.ord I asra ro comply $ ith all Cnyand Counly <br />oidinancc Md srar. ll$ rcldir8 to in8 coNtrucrion. dd hmby aurhorte repi6ntariv6 o f this Cily ed Counly lo €otd upon lhe <br />abole mqrion.d propsr] lbr <br />,\pplicant or Aesl Signllu <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsulation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <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 />,1 <br />FINAL <br />Certificate of Occupancy l L/U <br />Notes, Remarks, Etc <br />I x <br />I ,. ,LYIU <br />I <br />eaLh <br />9..1 -t? <br />rl <br />)L-. <br />-J-Ce a\ <br />*" -2{:ff7 <br />lt <br />-1'