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SITE.WORK DATE ID/SIG.COMMENTS O\{N ER AUILT'ER DELCAtrATION
<br />I hcrcb, aifirm utrds pcnairy {)r pcrjdry lhai I sm cxcnp' rtum rhc contlcloN Licctrs Lrw rbr thc lollo*in8 rcrsn (sc.70.rl 5
<br />Bosin.\\ and Pmfcs\nn Cod.): Any Cny or counry whi.h rcquncs r tEirnil ro cotrslrul. llrcr. inpR,!., d.mnish or rcPan {ny
<br />n .rurc, prturtu irs i*xa c..ko rcquircs rhc lpJ,licad Lr tu(h p.nni lo filcu risn.d {a'cnrtrr rhnr h.orsh. i( liccnsed lursmr
<br />ro rhc nmvhion\ of rtc Conrrscrols l.i.dn{d liw {Chaprcr 9. comnrmir8 wnh Scctiotr ,0m of Divi\ion :l of rhc Busincs ,nd
<br />Pdcrsio n\ codc) or rh.l hcorshc hcxcmpt rhcrcrio'n.trdrhc b0sh rbr lhc ullcscdeicmlltrn Anyln,hrionolScdio!71)ll 5hynny
<br />rpFlica {or stcnnilsubjcclslhc lprrlicanr lo acivilpenalryolnor nF crhM fivt hundr.il dollds ($5(D)
<br />-l-
<br />as o*ner orrk pn,pcny,,tr my cmpLyccs eirh *.8rl r\ rhcn $lc onrr^-nsarion. *illdo rhc work and rrr {dnr n mr
<br />n cMcd or ofcrcd to. slc (Sa 104,1, Busirc$ rnd Profc.snnr\ (odc:'thc O,nrrh i l-i.cDsc tjw docs noi apply ro m owncrol
<br />rhc Dnrn ny qk, hikls xr iqnorrs rlENr on who des su.h $ork himscll or hcaelf or rhnn,Ah his or h.r owtr c'nPl')rcc\,
<br />lmvidcd th r such idprovc'EnB m mr i ckk{ or ooaErl for nrlc ll ho\rrc,, rh. builli'rg or inprowrfttrr is $ld wirhin om )tr
<br />of.on{,lciii,n. rncO*trq Brildcr willhnk rh. bxrlr.norp$vinE rh tE or stu dil en buitl or nl{,ror rhc pn,Fny r.r rh. turlre of
<br />-1.
<br />us owncr oi r hc p' o|*ny. r.r cx.lusivcly c.nt&rirlg sirh li.ctrrd comador to conslrucl ll'c lojdcr (s& 7{}.l4, Bn{rcs
<br />,nd ft.lission cldc: Thc Conlracrols Licctrsc L.w docs nol !t'!ly ro ano*ncr olproPcny who builds or i,nprcvcs lhcrcon.
<br />ond who.onlo.rslorsucnp(+chwirhaConrDchnrlicn\cdpoi\r,trrt'rh.Co mdolsLtcntlrw)
<br />-lonrdemfl
<br />undcrSsrion-. a. & P.C. ror rhis rcrvnl
<br />Dol.. orn..
<br />uQatrE&5_cuufltNtalll)N
<br />DlillA.Strlra!
<br />I hcrhy rfiinn undcr Frrhyolrcrturyonc ofthc lalkNirg dc.lnrrri,ns
<br />lhr\cr \ill Hi' rinaCcnir,.nr..tCni\c roSclfl\urck *oikcr\'..nrlcfsrri{r,x\tniriddnrhySc.ri({rl7(x).lrhc
<br />lilxtr (iic. tu lhe pcni,nuncc ofrhc $ork ftn rhich rhc Fnnir i\ i\sucd
<br />rhcs.'kf(nuhi.hrhisFnnirrrissud.Mtworld\-..nrNn!fi,[ir\unn..crri.rsdpoliryiunihdrdc:
<br />PolicyNumbcr: Erpn sl
<br />-l.cnity
<br />Ihal in rhc pcrfortutu. olrh. work for Nh'.h rhn N.nir is nsucn, I rhill nol cmploy any pcr*rn in dy nrrtrtr.r
<br />R, N tJ lEcoft \rbF.r ro rhc solkcrJ corycnsnrioo 1,w\ of Clliforni( and rsrcc lhil il I rhorld h.Nm suhj.cr Io rhc
<br />sork. comp.nsrrion pmlnioN ofScc!ion r'T00 ofrhc Llbor Codc.l shlll. rollh{irh dnnnlr wirh rho$ Pmvisions.
<br />WARNINC Failur. t, suc workcs .onrpcie nr covcrrgc is unhwlul. rnd shlll srtjccr r. ehPhycr ro rinrinnl neMlrics ond
<br />civil fi ds u, h oic hundrcd thotrs.nd doll.s (llu).U1o). i[irion r, rlrc .o{ of co'nF.qrior, drnracs rs fr.vi,l.(l lbr lh.
<br />Sc.rni 1076.f rh.IihorCodc.inre.c$und{torBy sles:tltt/v
<br />DECI ARAT(TN
<br />I hcrcby!firflundcr p€nalryolpcrjurr rhd I om licdn*d nnrrcr pm*bn ofChnprs 9(co.rmncinA wilh Sccri.n ?fiX)) ofDivision:l
<br />or lhc Busircss rnd Pmnsions Code- rrd my liccnsc h in tull Lre tnd cfla.r.
<br />1nLlt \
<br />llli/p\K
<br />CANEIAUCUIJNIINDINIiJ(iENCI
<br />I hcrch, afih6dcr FulryorFrjuryrh,r rhm is a.ohsnkrion Lklins a8cNy lirr rhc Fnrn1mc orrhc uork for whi.h rhn rc,mil is
<br />issucd(s(. 1097.civ. c )
<br />A.TTIICANIDIiC].IISAIITN
<br />I hrfthyili u nd$ Fnrlly of tcrlury orc of lhc iollow edc.lirulions:
<br />Ocndirion Pclni( ArtEsros Norifi.rrion F.ilcrnl Rcgul,ridr\ (Ti'|c40. P.d6)
<br />-Rcquncd
<br />Lf, llq of Norifi cdi,!
<br />I crniltrhi rhr rcJcrrlr.!u[inr\ npt di]rg r(x{o. .cntr)vrl rrc nrrrtpli.$ld t) rlri\ tn'lccr
<br />-lccrlrayrhal
<br />lhlvcrc rhnJrplicatnn nni irr.rhd rhc rh)vc irntnn i)n hcoflccl llgtrtk,conlPl!*irhallCiryrtrdCounty
<br />o.dimr.r\xnd Srrrc Ir*\ rcldinI k) htr'lJii8.otrnfl.r n. iRlhcrchy0urhoriTc rc!.cscnrrrircs ofrhi\ Cirt rtrd Coutrly ro cnr.r nFn lhc
<br />ahovc nrcrr oncd fmFnyfor insFcri{nr parlxrcs
<br />*,., -t /t J l llApDli.nnl o. Asenl Siqnalure:
<br />,"-r,"" *-",0n*,, LUia L.
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Ereclion Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loorVenVlnsulation
<br />Roof Sheathing 6/Z//x >\66
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<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 Beport
<br />Flood Zone Certif
<br />FINAL $tqth ,\6\
<br />Certif icate of Occupancy
<br />Noles, Remarks, Etc.
<br />BUILDING. INSPECTOR RECORD
<br />trndcrt \Jre
<br />-
<br />t ndci\ Addrc$
<br />-
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