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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS Set Backs Forms/Steeli Holdowns Erection Pads UFER Ground SLAB Floor Subfloor/VenUl nsulation Roof Sheathing Shear Wall Framing lnsulation/Energy D rywall Ext./lnt. Lath Brown Coat N4asonry Pool Fence Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif s\5-Z^h'k{2)./ Certificate of Occupancy No.tes, Remarks, Etc OWNER BUILDER I'EI-CARATION I hs€by amrm rndo p<nahy ofpcrjury that I an cx.npl Foh lhe ConImclom Liccnsc LaN for lhc lolloNiog r€@n (S€c 7011.5 Busin6s and P,of6ion Codc): ny Cit, or cou , Nhi.h rqut6 r pdnil lo co6rrucl. alr6. ihprov., d@.lish or repan my sttudu.. prior ro its i.sumcq also rqun6lhc Aplicanl lor such poni to 61. a sirn.d sr"rdnd rhat h€ or $c is lic€nsen puIJUml ro lh. FovisioB of$€ Co,tracto.s l-io..s.d b* (cnrpis 9. Comm.ncins with Sslion 7000 of Division I ofth€ Dusin€s ed Pmf6sions Cod€) or rhar lE or sh. t.x.,npl lh6.fro md thc bsis tor lh€ all.rcd d@ption. Any liolalion olsdion 70.r I 5 by any appli.d foi a pmri subjea th. applica.tloacililp€.alirolnotnor€lhanfivrhundreddoll&s($500) -1, s o* nd ot rh. l'oFny. o ny .nlPlo!6 $nh saE6 6 rh.t $1. comF6ation. will do rhc No* dd t $MG is tur intsd.d or o lla.d lor elc (56.7044. Buin6 and PrcfsioB Codc ft€ cont dor s Licd. t-aw do6 nor appl, lo a own6 ol rhr porrly who builds or inptuv6 thd@n, ed wh6 dd6 su.h wJrk hlBelaor hd€l t or rhruush his or ho own chtloys. proride{l rhal sucfi i'.t.ov@rs e 'or intaddl 6r ofio.d fo' sh Il howd6, rhc hrildin3 or imprcrarcd G $ld vilhin o.. ,sr ofclmplclio!. lhc O* os Builjr $ill h.( lh. hndd otFovins lha h. or 3h. did mr tnild or improve fic preDqly rot rh. purts$ oa l.6 own{oflhe Fopcny. dexclusiv.lyconrh.rios \ith licoscd conhadouro coar ct lh. lroject (S(.7044, B6'n* .nd Pslsiod codc: Th. Conrraclois Liccnse l,aw do6 not apply lo eowns o lDorrry sh{, buildr or imptov.s lhdsn, ,nd *ho co.ta.k for such prcjdts wilh a (bnrmdo(s) lics.d puEuot I on.x.mpl undr S( I hdcby .finn' ud&r p.tah! ol pajtr I havr dd eill ,n.intoin a Ccniarcarc ol Consflt ro Sclf-lnsur c for wrkdi' cdnrpeftd r, a1 trovid.d lor bySdion l?00 ofthc rib.r coda for rhe p6aollMc. oalh. md for $hicn the pqnil is isued. -l have and sill mainlain workers Nnpc6.l n insranc., * r<lutcd btsdtion l7O0 oarfi. Labor Cod€. for lh. pdLnnec.of the sork lo' which Ihis pdnir is Gsued My wor lcru' co6p.@rbn iNuecc c.tri6 dd polic, nunrbq dc, Policy Nombd:-Exp;s: I ccnify thar in lnc Ffomancc olrhc \rcrl ror shich rhis ponir ir i3strcd. l shall rot anploy anr, p6on in any nr&nd s aq ro b.cone subjd $ rn worl6' conpcns,rion ln$ s ol C alilbmia. ed .s@ lhal if I should b€(oo. 3ubje! 'o lh€ *0*6' conrDctudion arovisioB of sdrion 1700 of rh. Ijh.i ('odq I slEU. tonhwithcomplyw h lhoe porsons NING Irailoie ro wr. Norkol compasalion covemgc is unla{ful, a d sharr qrblor m dplo).r ro fincs up ro onc hrtrdrcd thousand doll s n 1016.1'rlr lri-' {'.d. inrdsr and a I lErctry imnn uods rEtr.llyoiperjrr ll'al I a'n I of rh.ausins d I'rofsionsCode. dd my liccBc is in lullio.c€ad€u€cr Li.cdc( ldss: Licens. Ntrmber (axilaucuox-LEllM-ac[Ncv I h6cby artrn und6 pcnahy oi psjury lhal lhac is a codtru.lioi L.dii8 ae6.r lor the pafommcc ollhc wor[ aor *hi.h this Fnnn ir isu.d (sd. 1097. ci! c ). ATTII(ANIIEII,AAAIIO! I lEltry afiN trndd paahyoapqjuryonc ofth. follorvins ddlaalions: D€mohion Psnirs-Asbdros Nolificarion lj€ddal R.glhrions (1ille 40. Pan6) -Req!ted l-clld of Norifi.aion I r€gu lar o.s Estudi.s Nlrstos rc,noval a e nor applic abl. to I h is rmj (l rcad rhis applicntnrn dslarcr h.omply \rirh trllCnyand ( ou.ry c h\s clarin8 ro huilding oarhis CnyMd Counlyro cnrs trr.. lh ,"*,,*""vl ,.,",/t/tr/< T-Bar FINAL 9 (conmcn.inB eirh SElion 7000) orDivis'on l