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SITE-WORK ID/SIG.COMMENTS OWNER AUIU)ER DEI,CA&ATION
<br />I n€reb, afinn u.dd lcnalty oi p.rjury that I m erempl liom lhc co.ttcro6' Licen* tiw aot rh. follo*in8 rwn (Ss 70ll 5
<br />Busin6s ud Profsnrn Code) Any City or cou.ry *hich iequir.s a lsnir to co.s{ruct. alle. improvc ddnolish or rclJat &y
<br />sttuduq prior ro ns isudc€. also reqoiB lhc .pplicd lor such pdmit ro filc a sisn.{ stalqnst lllal h. or sh. i! licffied pw l
<br />ro rhe rov*ioB ot $e Co.raclors Licensed Lrw (Chaprd 9, Co,nmcncing silh Srliofl ?000 ol Dirisio. I oflh. Bcin6 md
<br />PNl6ioni Code) or thd h. orshc is.r.,npt lhd.6om ed thc bsis lor lhc allcS€d cro!,In n. ny liolaio. ofs€crio" 70ll 5 by y
<br />applicant aorapmnit suli(lsthc spplic.Dtlo acivilpen.ltyofnol morclh fiv€ huidred dollas ($500)
<br />l. 6 own6 otthc prop€ny. or my €nploy6 virh $a!6 a lbcir rle .oftp.M ion. \eill do lh€ sqk dd rhc slru.r@ 6 @l
<br />i ddqr or olrs€d aor sl. (Sc 7044. Amin6 ed fblssios Cod€ Tnc (onktcd's Lictue bw doc nor @ply to u oq6 oa
<br />rhe [llp€ny tyto builds or imprev6 ths6l! md *ho dB su.h $oll( hnnsclao! hmcll or lhmush hs or hd d*n emplor.6-
<br />ptuvid.drldsoch imrrovmrs 6€ ml i.tdd.d or oitGrd aorsalc.I[ ho\66.rh.btiklinS or irrForml issld*ilhinon ]@
<br />or (.l,l€rio( thc O*id Bui[ld *ill lBv. rh. hrdd olprorms tlul h. or sh€ did nol build or nnpot dc p@Fly for lhc purpoF oa
<br />-1.
<br />s oM.r oalhc Fopdr. m.xelusiv€lycontr(lins with liccas.d cootadoulo.odtud th. pmjsl (S(.70,14. BEi.6
<br />d ProEsion Codc l'ficcontrcroas Liccns. Law dd6 60r apply ro d ownd oapropcny vho builds or iirrov.s lh66n,
<br />,nd who .o.rft .8 aor soch pmjdts *ith a ContRdo(, licff cd puGrdl lo lhc conradoas tic.e Law)
<br />I ancremu utrdd serion . D.
<br />*"' \\-?,v-) (o*,*)4
<br />DICLASdIIAN
<br />I hseby amrm und€. p€nahy ot psjury one ohhc lollowi.s ddldatioa:
<br />-lhavcmd*illnai
<br />ain E C.nificat. of Co6dr ro s.la-lNurc for $rkc( @nD.nlolion, 6 r'ori&d lor b, serioo l7o0 oflnc
<br />tib.r Cod.. tor lhc pEaomucc of lhc wo* fo, whi.h ihc t6sir ( str.d
<br />lhav€andwillnroinrdinworkerf,conpcNationinsurake,crequircdbySationlT00oalh.liborCod..lorrh.ldfonMrccol
<br />thc Norl fo' Nhich rhis pcDnir i. $.d My "orkdr
<br />(onpcMion iBum.e .?ri6 dd polry numbd d.:
<br />,xpn6:
<br />-
<br />I cdiarrhar inrh€pdformatrceofihcNorl lor Nhichrhisp.rmil is iss'cd,, shall nor .dPh, a.! !€6on inanydeoE
<br />s 6 Io bdomc $bjd lo th. troris coip@rion la$s of Calilonia, and a*N thit if I should become subjel lo 'h.wort6s, compeNfltionprovisiocofselioo:1700oarhcl-aborcodc.lshall.tonh{'ithcomply\eilhlho$pov6ion3
<br />WARNING: Failur. ro sre workm' compederion covmsc is ula\rlul- ad shall subjd nn dhtloyd ro riminal lisEnis ud
<br />.i!il fi.es up ro onc hondr.n rhous d dolltrs ($100.000). nr rh...n of.ornt Nrbn. d as6 6 p'oridcd ror lh.
<br />Sc.tion 1076 ofnE Labor Codc. iotdd d atoney *_I,"," . l\-?-o-lt-
<br />r I( r,rNsap (1)N t RA('t()R
<br />DECId]AII9I
<br />I hr.by amm uodd postry of Fjury $, I e licosdt trddo prolision of Chaprg s (comodcins tr irh sdtion 7000) oa Division l
<br />of lh. Busins d PmisioN Code, ad my licoE is in tull lora dd .f(l
<br />CAIiIBJ]CIIANIINDINCACEN(I
<br />I hd.h, aflim undd Fmny ol psjury fiar lh@ is a coGtoclion lendi4 aadcy ror rhc !-aonndc. oallE "ort for which rhis lEoil is
<br />issu.d (sd. 1097. civ. c.).
<br />attlrcadf[EctA8arlox
<br />I hs.ty afm und6 rBahy ol pcrjury onc or rhc follo* ins d(ldalions:
<br />D.nolnion Pmns-Asb€tN Norificariof, F.ddal Rqularions ('rilk r0. Pan6)
<br />Rcquned LL{er olNorinc.rio.
<br />, I (drt) rhalrhe lcdoalresulol'oN rclad'n* 6b6L!e,n".Jltu( n.r ,'pfl'cdbl. ,o rhis Droid
<br />dG ca,rv ru I r,+c,q,.r rr,ts aepl'.,r,on dd s,ar. r hrr rhc abo$ inlonn.rioo is cotrar I aaie ro comply *id all ('rt .nd county
<br />ordi.onc6andSlateliwsElarin!robrildingcon$rudtuEddhtr.byarho.rcprBdlflliv6oflhisCnyddcoudryroal6utonthc
<br />ab.v. nEnrioned propdl lor insDeclion
<br />Appli.r l or ]\Bcnl Si8nrlur.*," z lr_L:_lY
<br />r*.ir**."rp.i"rr, X-[5cr--.r e<--S
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Roof Sheathing t z.r7- [8 b-ll-t.-'7
<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 />FINAL /-{7-/9 ,4"s.\o"4 2,
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc
<br />4*^
<br />/ -to ,.<.4
<br />+
<br />BUILDING. INSPECTOR RECORD
<br />DATE
<br />Subfloor/VenVlnsulation
<br />Flood Zone Certif.
<br />I iccns. Clss LitcdtNumbcr
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