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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER AUILDER DELCARATION I hr€hy alfirm und6 p.nalrr ol tEjury rhd I an.r.mpl torn th€ ContracloE l-ic.@ Liw aor rh. lollowinS ree. (s(.?011.5 ausirGs md ftofGion Codc): Any Cily or County s'hich r.qut6 a Fmit ro coNrucl. ahs. imprcvc, &nolish or rQan uy (rudu.. riorro ils isudcc. also r.quiB rh. appli.anl for luch pmil lo lilc 0 sisncd slaldnol lhal h. or sh. i5 licmsl puulant ro rh. provisioN ofthc Conlraclols Lic.nsed titr (Chaptd 9. Con.Eicing with Selion 7000 olDilision I oflh. Ausincs dld PofsionsCodc)!rlhalhcorsh€iscr@prlh.ctorandihc6asisfortheaucs.dcrcmplion.Anyviolalionofs..rion?0ll5bytny applica for !p6nil subjersrh. appli.am to acivilp.nahyofnot morclhe fiv. hu.drcd doll6 ($500). I. s o$ ncr oflh€ FoFtry. or my €nployc w h wa!6 4 'hci &1. .o6pdMtion. will do lh€ wort dd ln. $rucl@ is nul mt6& orotrcEd for ele (Sc.7044. Bcins dd PmfNioB Cod€: Tne ConlEclois Lrtu.Irw do6 not tpplyto M owndof lhe pmpoly sho hil6 o! imrrov6lh€mn. udvho do3 n(hqo hnns.llorh6dlorlhoushhisorhcro*n.mploy.6, proridcd rhar such inpmlanm6 m nor intmded orofid.d lorel..li ho*od, lh building or inprovmat is eld wnnin onc yw of compldion. th. O",.s Duildd will ha\r thc hudo olp(iving rhd h. or shc did mt l,rild or imFoir lh€ plopqly tut lh. p1iro* ol -1, 6 oM6 ofln. FoFlr, m .r.lusi!.ly .onradtru *nh ricd.d contradoN to co.slolI rhc Fojd (sa 7014. &tso* a.d Aoftshn codcr Th. CoDrrrclo.s Lic€se L.v do6 nor apply lo d o{nd of propdy wno builds or i prov6lh6on. and who conlrrcrs lo. such Droj.ns vith a ConrEcto(s) licms.d pu6uMl to th. ConlElor's Li.ce kw). ( DECIdIAIIO! t h6cby affid undd psDlry fpdju.yon. ofrh. aollowin8 ddltralioN I havc dd willm.inrain r cdincar. olcoBni to SclfJnsurc ior *orkqs coor!tuarion. d pbvidai for by Selion 1700 oflh. tlbor Codc, foi lh. pffonnmcc oftn. wo' k aor wnich lE p6nxl is issued. Ihav.andwillmaint.inNorkcrscomFnsalioniGuraocc.asr.qutibySErion1700otthcLaborCode,forthcpdromMc.of rnc $orl for rhicn this Fon is isucd. My rdk6 conpoetion insu@cc cmi.r Md policy numbs d.: I.diry$al in $c pdlotuc. oflh. *ork for $hi.h rhis pdmn is issu.d.Ishallnol dploy any p6en in an, n nr s 6 ro b..o6. subjer !o lh. $o 6'comFN.lioD larsofCaliiodr!. dd age$d ial sbotrld bc.onE subJel lolh. .-M*d conpssrio. pmvilions of sdion l T00 oflt lihor Code l slall. fodh*nh conPly vith rt F pmvisio6 WARNINC: Failur. ro su. wort6 onp.6.rrion co!d8. is ulavtul. and slull subjsl & 4plorq ro riniml FEI6 md cilil fin.s up ro on. hundred lhousd dolln ($100.000). i. Srrion 1076 orrh. Lnbor Cod., inrffir &d,trotry's f6 DECBAAIION I trftby amrm undq poalty of tEjury lhal I m li.dEol und.r Fovision olchaplg 9 (comdcins of the Bsin6 d PofsioN Codc, d hy !i.ft. is in lull forc &dcffer CONSTRUCTION LENDINC ACENCY I h6eby lrm und6 pdalry of pd!ry rhd rh6. is . coNrruclior k dins asdcy for $c psfonm.c of th. *ort aor pnich lnis pdnit is issu.d (Sd 3097. Civ C.) ATPIICANI.DECI.ASA]IA! I ndlby &fllm und6 p.n6hy of pqjuy on€ ofrh. aollosif,U delaralionsi Danolition Pdmits-Asbcsros Norilic.tioo !-cd6ar Rcgulariod (Tillc 40. Pd16) Requt d LardoiNoli6cation I cdi& lhrt rh. fcdcral resulalions rcsudins 6b61ot Enoral dc .or .pplicabL ro tht poj.tl. Crttn,',al I have Gd lhG aptli.arion and sr,r.rhat th..hov. inlonsalion is cord. I asrd ro conplywnh allcnyand Coury Sratc InNs Elams ro buildins .oGttud io., .nd re!.66taliv6ofrhb Cny Md Cou,lyro sl6 urFn thc abolc nc.iioned po!,^ny for i6pe-lon -il ^p x-l--)st Set Backs Forms/Steel/Holdowns Ereclion Pads UFER Ground SLAB Floor Subf loor/VenUlnsulation Roof Sheathing Framing ln s ulation/Ene rqV Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req De U Final Re port Engineer Final Report Flood Zone Certif. FINAL 1 tLla D/rm 61,-*5? Certificate of Occupancy tu Notes, Remarks, Etc ,,^,". c 1-JrAO I-ic.nseclars: Lic€n$Nu'nba: Contr..lo.i_ L..ddt Ad.lr6s: Shear Wall