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SITE-WORK DATE ID/SIG.COMMENTS OWNER BUII-DER DEI,CARA'NON
<br />I hcrcl,y nlfirm undq Nm lry of Frjuty rlur I inr cxctrrt'r rom rhc C nka.hn Li.ci\c h! r.r r hc r(rlowing rcN'n ( s.c ?0.1 1 5
<br />Bu\n'c\s md Proac$ion Cirlc): An, Cily or Counl, qhich rcquircs 0 pcrnrir Io con(d.'. .lrcr. inpm\e. dcnmhh or E0rn rry
<br />(ru.rurc. prior b ni i\suDncc. al$ r.quircs rhc applicanr lor nrcn pcnnirro filc 0 si8ncd srarc.rcnr rtut hcor shc n liccnsed pururnr
<br />ftr rhc pmvi\i,,ns ol'ltE Cotrrraclols Liccnscd tiw (Chlprcr L Conrm.ftin! wilh Scciiotr 7000 of Divhdr :l ol thc Bu\imrs rnd
<br />Pmrcs\io.r Cnle ) or rhlr hcorshc hexcmpr rherclrom.nd rhcb.sn for Ih. illc3cdcxcmpri.n AnyviohtionofSdionT0Sl56yrtry
<br />ap!lica lnr. pcnnir subtc.rs rhc +tlic,nr t, r.i!ilpcnaliyolnor nnrcrhu fi!c hundrcd dollln1$5110)
<br />I. nt owi or dlc Fn,Fny. or mr cmnloyces wir h \'rscs rs rlrir solc conrp.flsarion- will do lhc ror k ml
<br />'1..
<br />slruduE n nol
<br />intexldl or ollircd lor Mk ( S(.7O1.1, Bu\incs and Ptulcs\ions Cdlc Th. Conrrr.k, s I iccnsc ljs dms nor spl)lv h r. otr rcr ol
<br />rhd l,n)Fny who huikk.r i'qr.ws llENn. md sho dds {kh w.* hinr{clfur hfsclfor rhtuu8h hil or h.r owncmfl,,yc.\.
<br />,rovidcd rh,r vich imnnrtnrtrls fl! nor idcnLd or ol|rcd lbr srlc lli lar*crcr. rhc bdituing or nnpmrnrtrr i\ v'H $irhn onc ttu
<br />oiconlrhrbn.rlrORcrAtrikhrwillMRrlrhurdcnofpmvingrhidhcorshcdidnorhuildorirrnx!lhctDpcrryforrhcpurporol
<br />l, ^o*ncr ofrl[ nrop.ny.,nr.x.lusivclr- contr crir8 sth ll.cn\cd..ntdrs r..Dn{tucr rh. tr.l..t (Sc..7(11-1. Burnu\\
<br />rnrl Atrlirsbn Codc:1hc Cohr..rtr s l-iccn\c l-rw doc\ nor apply lo rn o+T.r oipr)Ir(y slo huildr or inuovc\ rhcrcon.rnd who c.nrr&rslor{ch0mrcchwirh.conrr.r)nnli.ciscJlu^urnrhrhccdnracrr'\l.iccrs.l-as)
<br />I rtrrdcnrfl uodcr Sccli,,r
<br />tYoatrr&Lroufl:Ns .lIl)N
<br />DECTA&I-I]A!
<br />I h.rcby.fllrtrrrndq p.nrhyof pcrjuryoncol'lhc ti)llowilgnc.hrdn,ns
<br />Ihrvcrelwilltui ainaCcniliclrcofConscnrroSell'ltrsurclhr$orkcs.onDcnsdion.0s!rcvidcdlorhtSsrionlT0{roflhc
<br />Ilhix c{xlc. in rhc ll.rforromc otrhc uork for which rhc |Rirnn is nsucd
<br />_lhnv.ald uillmri irnr sorkcr { .onrBisdnnr nsurancc. \ rcquncd by Srcri,,n l7(x)nlrh.l-rborC.dd. lnr rhc pcrform'nccof
<br />rhc qorl iorwhichrhis pcrnrilis i$tr1\t. rrr workcr. .onD.is,ri,m in\uruncc.,tricr Mdlx,li.y mnrhcr c:
<br />Sl,.tk Rr^J
<br />ll35er 6 2b
<br />lccnilythriirlrhcpdrf.nmnc(,frh.workf{r*hichthispennilih\ucd.l\hnllnotcmpby!.}pcsoninlny,lnner
<br />s as ro hccom subjrl to rhc workcr omFctrs.rion laws.rcrlilofti,.ond.grcc rhd irl should h{.m subj$r ro rtr
<br />workcn cornpcnsriotr trcvhions oi SNrion lTl of rh. I f,t i C(rl.. I \hrll. fonhsnh o dy wirh Ih.{ pmvisbns.
<br />WARNIN(;: Frailurc t, $.ur. w.rkr^ contpcialrion covc.lsc ir unlusl'ul- und shall sut'jecr 0n cmrrloycr lo cnmiNl lcnaltlcs lnd
<br />civii fincs up lo onc hundrd rhou{,ld Jolla^ (Sll)O.O(x)). in oddirion to rhc (ost ol coml].nration. damsci as pn\idcd r'or rhc
<br />Sccrion 3076ofrhc litn cdc. inr.!c{.nd drromy\ fcrs
<br />-t'\. tt, I--'D,t, /l/a/lh
<br />^optie, {W\ d-Ll "Ll,/I lLIrNSln ( llNTItlcTOR
<br />!&CTABAIION
<br />I hcEhy rm.,nundcr p.nalrt.rFrjury rhd I am li.ci{d undcr prcvGn,n ofChaprs 9lconmncina sirh Sccri..7(x[).rDivkio..]
<br />or rhc Bu\incs\Md Prorcsions Codc- and
<br />'ny
<br />li.cns n ir iull hrcc J cri:ccl
<br />K \or7g3l
<br />,,,"11261(t)dtralz2
<br />call.IalcuoNtENDlNcloElcr
<br />I hcrchy affio undcr lEoalryofpclurylhll thcrc n d.on\ld.ri,n Icnding lgcncy lor rh. p.rlolmrcT ofrhc worl lor which thi{ IEnnn n
<br />isslcd (Scc 109?. Civ C )
<br />AISUCAULIIEq,AAAIIIIN
<br />I hc.e6ylninnundcrFnnltyof !.rjuryomof rh. folk,wnrBd{l iunsl
<br />Dcmolilion Pcflnih.Asbc(os Nori,icalion Fcdcrul Rceulrrions(Tillc 40. Pa 6)
<br />-Rcqutcd
<br />t tlcr ol Norilicalion
<br />-l..nifyrhar
<br />rtc lcdcnl rc8ulerions Esardins nshestor rcmvnlm not lpplicoblc ro rhh prcjcr.
<br />ul[i rcn'ryrh l h:rc rcad rhn aprli.r"on rd nx,c ihir rh. aho]c infomrion iscorer.IiFe r. comply wnh allCiryaod Cornry
<br />ordinnnos .nd Srarc bws rclrlinC ro huilding..nstu.rion. lrxl hcrthy rhorizri.[c*nrari!.r.frhisCiryadCou.ryro.nrduponrhc
<br />abovc nrnri.n.d p6pcn, r.r inspdrii,n puixxcs
<br />,\p!lir nl or,\{tnr Si!trrturr t
<br />Fcmile n.me lp.inl): Z
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsu lation
<br />Roof Shealhinq
<br />Shear Wall
<br />ln s u lation/E ne rgy
<br />Drywall
<br />Brown Coat
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil.
<br />'6 lt5 lY 5r 8a
<br />Certificate ol Occupancv
<br />Notes Remarks, Etc
<br />BUILDING- INSPECTOR RECORD
<br />Framinq
<br />Ext.i lnt. Lath
<br />Ivlasonry
<br />FINAL
<br />Lcndcil Addr.$
<br />- t2_5 / lb
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