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SITE-WORK tD/stG.EOMM!NTS
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<br />OWNER AUTI,DER DELCARA oN
<br />I hcrchy oififln und.r pcnslt! ol lcrJu.y that I !m cxc0pl lioar rhc Conllacrur t,icenE L:* ror rhc rolk,winS rcrsn (S$ 7031.5
<br />Busincss a Pmfesion Codc): Any Ciry or Cou y which rcqlircs a pcrdir ro consflct. ,lb. inProvc. dcmolish or Epan lny
<br />dn.rurc. pri{, ro nr is!trrc, nko requt t rhc amlicxn' fn iu.h Fmir Io fiLa si8rcd stdenttrr thol h.o, sh. is li.cn*d pu^udr
<br />r,, rhc nrovnions of lhc Conrrrcroi( Liccnrd Lsw {Chrprcr 9- Comftncin! wirh s.c(io. 7tx$ ol Divhion 3 oflhc Busincss lnd
<br />Prorc$ionsC.dc) orrhd lr.rshc kcxcmpr rh.i.fr.mdid rhcbasis for rhc rllcgcd cxcnrl'lion Anyviol ionofseriJnT0ll.5byhny
<br />0mlicrnrioripcrmnslbjcIsrncapplicantloacivil,,cnoltyofmrnnrethanfilehtrndrcddoll-s1S5{D).
<br />A]ds owm, or$c pbFdr. or my.mployccs with wJB.3 N rhcir q,h co qEnslbn. will.h rlE woll ad lt ntrm. to
<br />n crdcd oro,lcr.d for lnc (So.?044. Busincss and PmLssions Codc Th.cr)nirscroisLic.h\cl-,wdocsnorafdyto0nowrcrof
<br />rh. pmrcd, wh)t ilds o' itr{rft*B rtrMn. drld qlxr dds skh r.* hnnscll.r h.$cltor rhrough hi\ or hcr oen cmpk,yNs.
<br />nmvidcd thol such nn rovcmnrs m nol inlcnlcd or o,icEl lor sb lf. howcwr, rhc hoilding ot lnDmvcmm is sold wirh onc
<br />'eeorcorpLrion. rt* O*mr Buildd wil hah dE t [d.n of pDvinS rhd h or shl dn mt borld or iqmr Ur Implny L, Lhc ,urFe of
<br />l. r\owncrolrhc |x,Jrny. aDcxclusiv.lyconlrrriD! rvilh I iccnsctl co nt kt,s t, cornfl.l rlr foiccl(s( 7(I{4. Du{ncs\
<br />rrxl l\I,r6\i)trCodc th.Conracntr\l-iccnsct-trwdo.\.'rnplyr'anowDcrorr)pcayq'honuiftorimpn,lcs'hcrcon.
<br />aid who .otrtrad{n)rsu.h pil.cls wirh n Contict)(\) li.cnscdluruinr rolheC nrracrr's l-icci{ LJw).
<br />I.trncxrnror uidcr Sclrn,n . a;"- C -2 Zzg**% -zll)lf,E&tloufENlalro!
<br />D]ICL I]AUAN
<br />I hcEh, ai,irnr uf (lcr F-nalry orpcrjury onc nf ihc followin! d..lrhrniis:
<br />-l
<br />hlvc !d BillEinnin ! C.nificrrc orcon\c.i rosclr ln\rrc ror work!tr competrsarion,as pmvilcd lor bysccr n]T0oorlhc
<br />t hor Codc. Ior thc l)erforrorcc oI rhc *ort lbr which lhc pclnir is h\o.d
<br />I hrvc ond will mainilin porkcrs comp.nsation insu.rncc. as rcquired by Sccrioo.UoO ofih. tibot C.de.lot thc Frlornuncc of
<br />lhc wor* lorwhi.hlhh pcrmil is issucd My workc onrpcnsriotr i.suranc.cadcr rid poli.y.umbctd.:
<br />A/*rrr rn r ru rn *un *..c ol rh. work for which this lEirn( is rssucd. I shau nor cnnb, m, I}.r$n rn ,ny nran.cr
<br />h a\ lo lEcom sublrl lo lhc *o*cs cotr{rnsrlion lawsofcalifoni!. and asi.t rhr ifl should ntom sul,jd ro rhc
<br />workcs ompctrsdlion provhions ofSalion 3?00 orrhc ljh.r GiqI shall, r.nhwirh$mply wilh thoE Ptovnions
<br />WARNINC: Frilurc k' surc w.rkcs .on!*herion ovcDgc ie unlawtul. {nd snoll suhicr !n cmrL}$ ro rimn,l tf,mlri.s.nd
<br />.ivil lincs rp t, otrc hrhdrcd rhouund dollds lSl(D.(x)()). iMddir to lhc (o( oi con,|{D\rti,n,. drnug.s ns
<br />Sccrn,n.10T6 otrhc trtrtr Cold, inr.es Md .iky s fcrr.>>
<br />DICI.ABAII9N
<br />I hcrbyllitm ul(lo penalrrolncrjury rh lumli.cn*dLndcrptuvisionolChnpls9(€onnncncinawilhSc.rion?mo)orDivkionJ
<br />of
<br />'hc
<br />ausims and Pmfcsions Codc. ard my ltcns h in tull forcc arrr cfr€cr.
<br />CONIIBI]CIIONIENDINCIGINSI
<br />I he$by aminuidcr Fnahy or p.rjury lhdl thcic ir r.uiructi.n kMitrB 0scncy forlfic pcrlortutuc of(h. work lor rhich lhh !.anit is
<br />issuen (Sec.3$7, Civ C.)
<br />ATILIgANfIIEI;IJAAIIAN
<br />I lEEby dfiirD undcr pcnlll y ol'pcrjur, orc oilhc lbllowirE dcclurriuN:
<br />thnnnirion Pcirnils.Ashcsros Norilic0liotr ltderal RcBullrion\ (-lirle 40. Pan6)
<br />-Rcquncd
<br />brrcr or Notifi carion
<br />_l ..diry rhd rhc rcdcrd Egtrlario,s e8,rdin8 asb.slos !cn$!!l uc nol amlicahlc lo rhh pn j.cr.
<br />d&aty hlt t nn\c rcad $n applicariotr and norc rhar rhe ah,vc informarnrn i\ coft.r.l.!r$ b.onplyvirh rll Ciryand Colnr,
<br />odiMtrc.s.nd Sturc L3ws rldins ro tuildins consrtucrion. ud hcrchy aurlnriz. rcrc*.rarivcs ofrht Ciyand Counr, lo cnrcr upon dc
<br />fi,vc mdn,ncd ln,|f,ny to, iNp..rionpu /8,\|rlrliuul nr ,\,turl Sigrtrl urtX 2
<br />c/t t1
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loorivenVlnsulation
<br />Rool Sheathino
<br />Shear Wall
<br />Framing
<br />ln s u lation/E nerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />D eputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL z/u/D -"Mut )
<br />Certificate ol Occupancy
<br />Notes, Remarks, Etc
<br />BUILDING- INSPECTOR RECORD
<br />DATE
<br />"^,,, 'G'22
<br />txndn s Addrn:
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