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SITE.WORK DATE ID/SIG.COMMENTS O\TNIiR BUTLDER DEL('ARATION
<br />I hd.tty lrEi u.ds pqdr or Frur' lhr I m adrpr 6om rh. Conrcl-r L.c.* t { lor E folb$i,* .s)n {Sd 70ll 5
<br />BEind .,n ftof*k'n cod.) Aiy Cny 6r Coudy *hth r.quiG ! rEhrr ro coonrud. !hs, inFovc. drtulath or r.r!n ey
<br />slruclw. prbr ro ir! isutre .!. ro+iB rh. +plicsr lor ru.h Fmir k' nl. ! rig.al $ndor fin ll or si. i licqs.d p@.rn
<br />'o
<br />ilE FDrilbB of th. Cont&l( t l-i@!.d lrw {clDpld 9, Comdi.s snh scrio. 7000 oaDnnio. 1 of
<br />'lE
<br />B6iK rd
<br />PrDfdioB Codc) tr rn l E or !h. ! amF lha.6oh sd rh. bair for rfi. .lk!.d dmplion. A., violrion olsrlion 70.! I 5 b, lny
<br />applicd for a Fhil sublrl! rh. imli@r ro.riril!.n!lryofnot mr. rhs livc hutdr.d dou&r lt50o).
<br />l. 6 o*G of rlE FDFry, or m, mdotc *nh $d!6 a rhci. $L onFMion, *ill & ilE sut id ErME i r
<br />n addl or ofiq.d for sL (56.7044, BNiE ud ProfdioB Cod.r Tnc ( onrGcrdr'i Ltre tlw do6 nor 4ply ro d osnn oa
<br />rh. Fq6y whi Eril& n ing!€ dEm !d *lb .16 uh Nn hi@lf or lE*llor thmuah ha or hd o$, dplolta
<br />Fvd.d lhd tuch inF.rsEG e d nan d motu fm sL lf. l[q66. EtlilditB or if,p.o(tlrd i,ld vain or rc
<br />oaconpldion. fi. o*M Builda "ill h.v. llE hrda of lmvin8 fid h. d sh. 'jil mt boi[ or imFlr. lh. plnFty for llE pi[IrE ot
<br />I, s o*ffi oarh. F.Fry, m a.ldiv.ly .od.rdinS + nh l(qlal contldoB ro codtud rlE Fol.d {Sd. 7014, &8tr6
<br />rd ftnli$in (bdc: Th. ( onrcro Licd. Lls d(€ nor lpply lo u ou n6 ol pIopsry wlt' build! or inpmvd $a6..
<br />sd rho odms for sh p.oFlr snh. (-odd.(r) li€!.d p(lsd
<br />'o
<br />th. Codrrcnx'! l-i(og l.u)
<br />_l ah.rdfl undo sa'
<br />Drr.: Orn6:
<br />woR($qsa:()[rPEns rroN
<br />DECIJAAT!,N
<br />I h.r&) rmm u.da Frh) ofFjuD- oE ofih. foll,o*fs &.,s!ri,6
<br />-l
<br />h!v. dd will n$inr.in ! Cdituncof CoMl ro S.lf-lcw tor wtra onlPdDlion, a prordcd for byselion 1700 of(h.
<br />t tu Cde ffr lh. Ff(,1rlm. of lh. E t fm stth lh Fmn ir isrd.
<br />-lhr\.andN'll'narnta'n wo*.n' ro'np.Nsrion insuraRc. as r.rtut€dbyS(li{,n.1700orlhcl.hir(idc.forrh.p6aonn.n..of
<br />rh. $o,I roruh'.hlhEpqr B isaj M) *.rld' co'nlEsd$n rNutuc..u. 3,rl fnh$ numb.r a.6^
<br />_ErpiE
<br />_l..diry $al in rh. pcfomuc. of rhc worl fo, which rhis Fn i5 ns.!.I shau nor anploy &y F..n in.ny me.d
<br />$ Bl.hcorshidbt,Eso d'omFdio. L*!olcdifomia ud+rlhr ill CDlld b.com rbiIl lollE
<br />"ort6' onFMion FolirbB orSdion !700 of 'lr lltor Colq I rlEll fonnrht snPly *nh llDr provi'ioB
<br />WARNINC: Flilurc to su. work6' compGMlion covdls. n uhwtul. od 3h.ll rubjdl d dpLF lo oimintl pauti6 dd
<br />civil fuB up io oE hun<lr.d rhou$d &llB (I100,00i)), in ldlnbn ro ilE coe of comFt!.rio'! drn46 a prorilal for lhc
<br />S<rirn 1076 orrh. L.k{ ('o<le i 6.n rd.nor.ir lG
<br />e- l,>1, *t -l-.
<br />ug.}rgl(l).sl&tr.l!.lB
<br />l1f(JAal.l.Qr
<br />I hdr5y .mm u8ls pcoalry of pojury lhrl I d licosl urds Fovlion of ( hlprd 9 (con1lr@ ins wirn s.dbn 7000) of Dn ilion l
<br />oa rh. BuilB.rd Pmf6i,B Co&, nd mr li<* ir in tull foc d.Odre 24=+&
<br />tz-(rs (, g- ,n**",* @^--L d::^ 5;rz-c= \ t r-
<br />(alEralcDQ!.tllDlu{i.rcEd(r
<br />I h6.by lmm und6 p6ahy ol pqjury lhd lhs. i3 a snrruclion kndins is6cy for lhc psfomu.c of rh. work lor $hich rhn pann i!
<br />isu.d {Sd 109r, ('iv. C )
<br />AfIUIANL.AEqIJAAITA!
<br />I hddy lfm u.dd pa.l, of Fjury oE ol th. folhsing dclIrioN:
<br />Da@liion P@il^rbdot Nori6.aio. F.da.l R.suLrioa lTnlc t(). Prn6)
<br />_R.quir.d l,lrd of lhriLrio.
<br />-l
<br />.diay lhd rh. Ldd.l r.8uhl n'N r.3rdh! ab6n)r Eno\ rl r. nor nr4,li.abl. h rhir roJRl
<br />-l
<br />cdr,t) lhd I h.\r ral ths lprlrll nrn srd lxc I ha rh( .bor c rf.tu i(). B cord I aara lo coq,l) tr nh all ( ir) ..d ( oudr
<br />odium6.td Sldc t2\! rclrilB lo lrlrldllu coErrudrn. Erj h6.t, !ullEn/. rcpG. a'v6otlh6Cn) t dCounr' r. dr6ulmntrr
<br />ih.\. hnr ion.n lh{.n} for iNperion nurpos
<br />^pprion,
<br />or ard, sh,,u* [.!-=V.- \f-":s o.,., \?.( r>] rP.
<br />P.mi,F..m.(prrnr): L[-Es L-,.-r-o
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing
<br />ln s u la tion/E nerg y
<br />Drywall
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />En gineer Final Report
<br />Flood Zone Certif
<br />'.z-\FINAL t'>lzlla 4D/
<br />Certificate of Occu ULpancy
<br />Notes Remarks Etc
<br />BUILDING- INSPECTOR RECORD
<br />Ext./lnt. Lath
<br />ilzt**
<br />r -i., €&r -t- <--F,rs--r,z-<..,r --<
<br />\,*r.-:-
<br />I
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