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SITE.WORK DATE ID/SIG.COMMENTS oWNER BUII,DER DELCARATIoN
<br />I hcrehy uinnr undcr pcn0lry of pcrjury rhar I dnr cx.nrr rrcrn rhc CtJnt,.t'n Li..nsc ha ror rhc lblbwing rcrsntr isn Torr r
<br />sxsnc$ und Prolesion Codc): Any Ciry or Counr! *hich rcqtrircs . ltrmir io con(ruc1. ollcr. imtmvc. dc.mlnh or rcpan ani
<br />(ructuE. prinrd ir\ i{\urnc.. otoquiErrhcDpl,licanlntrsuchpcrorirrofilc!\i8ncd(lrcrutrr rhar lror sh. i( liccn{d pursuani
<br />b rhc lmehions.fuhc Conraciois Liccn{d Llw (Ch{prcr 9, Conrnrrcin8 qith Scdion ?0m ol Divhion 3 ofrt{ Bu\incs !od-
<br />Pmfcssions Cudc)or rhar h.orshc iscxc'npi rhcrcfromJrd rhcbasir aq rhc allcgcd cicnlPrn,n AnrviohrnnrofSerbnT0:ll5byriy
<br />rpplicur lor arcrnril suhjcclsrhc ap,rlicont lo 0civilpcfflry.rndr trFrcihrtr livc hutrdrcddollnm(.$5(x))
<br />-1.
<br />ul owmro,lhcpmncny.or mycnplorccs qirh wn{.r N rlrr \,k con{rnsnri(rr. willdo rh( worl eel rh( dnrrurn nor
<br />inrcidcd or oifcrcd f{r slc (Sa 7(}t4. Burinc$ rnd ttofc$n,ns Codc:-lhc Conti.ror'. Li.ctr{ Lo* des nor opply ro mowncr ol
<br />rh.Imp.rry who $lildro. inworcsrhcm!, iwhod€\such$o*hinNelforhcr*lforrhn,u8hhnorhfiosncnlroyccs.
<br />pruvidcd rhrr srch i |]R)v.nrm\ dc nor inr. lcd oroffcr.d f{n {t Ir. h)q.!.i rhc buitlDg d inuov. r nbUtrilhhorc}t-
<br />ol'oflUlclinr.llt Owncr Builds sillhflr rhc budcn.fptuvrg rlatr h. or \ht did ior bxild or infn,vc ih. ln'Fdy lor lhc Nqi,s ol
<br />I.a\owncrolrhcpn,pdy.ameichsivclycoDrEcrinrwilhliccnscd.onrra.ror(hd,n{torr(h.p(trr(sc.70tl.Buincis
<br />and lh'rassi,. Codcr lhc Co r,.lor'sLiccnscL,wdocsnorrtplyi,inotr $.ftrop.dyeho hulldsor inrrovcs rhcrcon-
<br />and who coor,!.hn,suchrojecrswirhaContmclo(O li.cnscd oursullr ro rhc Conrracrois Licensc l,$)
<br />I detnpr u.d6 S.cr
<br />TOBTIiB.SI:OIITENIAIII.I!
<br />DECLANIIIION
<br />I hcrchy.tli.n uM.r FcMlryol ,trrjuryors ol rh. inlhwing dr.Lrarnns
<br />lhrlcx'ldwill hrnJi'rrCcn,liorrolCon\cnlt,Scllln\ur.litrsorlLc^'(nnrD\rr(nr.$p()vnLd,(rhtS(rn 37m.lrhc
<br />trtxtrcotte, rnrrhc p.rtuiinnnccofrhc !u[ fttr wiichrhc Fnnir i\ isucd
<br />_lhrvclndwillnNintnrworkca coDlp.nsdiotr i,Eurik.. rs lcquied 6y s&'io. ]rtro ollhc tjbor Codc.lor lhc pcrfonBrEc of
<br />rhc wort ior shicn lhis pcrmil is kruct. My worksl conp.nsrtion iNu.rEcdnicr ffn loliiy trunrh.r arc:
<br />I ccdifylhar in rhc p.rlornBn.colrhc wort hr whi.hlhi\ pcrmil is isucd.l \hrll orc ,rloyEnytc^on in Dny.rnnci
<br />$ {s ro b..orm suhF.r ro rh. *o*crl enrp.nsartun lrws of Calituinh, nrd .8rcc rhd if I }hould bccom subicr lo rtE
<br />sorkcn'conrp€trsalio!flovkionsotSccliorl?0oofthctitrrCdqtshall.rhnhwnhs'mpl!$irhlhoscpovi\t,n\
<br />WAXNIN(;: Frilurc ro qrurc woikcs'.onrr.ns.rion.ovc.Jgr i\ utrhwful. Md rhrll subjcd & crnfbrrr lo simrrlpculrics and
<br />coDpcnsdnnl donE8c\ as pmvidcd f{r rhc acivil hrcs nt) r. otrc lr rcd rh.usitu d.llra (SI(X).UX)). In addirnnr t, rhc.os
<br />(dlc, i c.c! Md iuorfty s l.c\
<br />I h...hvrnntr,unJ.rJ[r lrtol I)rrluryrhrr I xD,licch.dtr ion of Chrprcr 9 (co'nnrncing wnh Sc.ridr rUotr) olDivisntrr l
<br />or rhc lrusinc$otrJ Pn)resn,nsCodc. a.xl nry liccnsc ir ir tirlllorcc mdcflecl
<br />tc t8
<br />C(TNS'IRUCTI(IN11]I{DIN(i A(;IiNCt
<br />I hctoby rffirn u{ler reulryofpcrjoryrhar rhcrc h ! cotrsrrucrion lcndi.s uscnc, for rhe p.rronumc orrhc wor* foi *hich thh !.iinir is
<br />hsucd (Scc 3097.Civ C ).
<br />l(c'rLly rlrrrhc liLl.'rl r.!tr1,'1 (rN
<br />'rsrRh !r(LrNr k^rlr'.trfr,t)tl.rhr(,rhrI',)r.r
<br />-l
<br />ccniiy rhrl I hrve rsd rhis amlicalionud (rrc rhar rhc rtbrc irlond
<br />o/,9
<br />ordinarc$i Skrctiws,clarin8 to huildinsco
<br />otlivc nrDri,,rd p6!.dy rir iN
<br />,{t,Dli.rnl o. Axr l Si,rn ltrr.
<br />FP
<br />iotr is comcl I asB lo comnly wirh all
<br />rizc rcprcenlalives oflfih Ciryund Cou
<br />*,.' -7/t
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsulation/Ene rgy
<br />D rywall 1
<br />Ext./lnt. Lath 1lt .t tvl nA,sff0.'-ha/
<br />Brown Coat 1
<br />ltrlason ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL I tn fi/l \tulrr-te/
<br />Certificate of Occ upanCy T'l L
<br />Notes, Remarks EIC
<br />BUILDING- INSPECTOR RECORD
<br />Flood Zone Certil.
<br />C"xrr
<br />?oli.yNu.rb$: Exptcs:
<br />:^:,,^';i4i;
<br />AIIIISANLDECI.ABAIIUN
<br />llb$ya,trnuidfi Fnbhy o, Frju., on. orrhc rollowiis dcclararions:
<br />Dcmolilion Pcnnits-Ashcslos NoriliQlion rcdcralRcsulations (Tirk.r0. Pon6)
<br />Req!ircd Lclrcr olNorifi carion
<br />f --f------
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