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SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I h.eb, aaam undo ps0lry olpdjury rhd I en .xonpr fmr rh€ Contidor Lic.ns. Lrw lor the aollowiq rqen (S€c 7011 J
<br />Dusin6s and |lofsion Codc) Aoy Cily or Cou y whrch rcquir6 a p.mn to coGltucl. ahq. improvc. d€oolish oi r.pat ey
<br />struclue Irior ro "s issud.€. alsn equir6 rh. appli.rd tM sucn p.mil to lil. . sisn€d slalmql tha hc or $t b li.md psudt
<br />ro rfie piovisiom of $€ Contacrof! I-ic.n*d Law (Chaflr 9. Comr.n.in! *nh serion 7000 of Dirision I orlhc Bcin ss dd
<br />Itofe$ions Cods) or thar hc or shc i. exchfl thd€fror dd rh. h6sB lor tlE all+cd .xdlplion Any violalionoas..lion 70115 hy any
<br />appli.ant for a p.nnn 3ubleGrhc rpplicanttoacililp.naltyofnotnorcth filc hun&.d dollrs (S50o)
<br />I, N oNrs ollhc prop€ny. or lny .Eploy6 *{h {o96 al rhetr $lc .o,nptraliof,, rvill do thc worl ud lhc sltu.ld. i! mr
<br />inrE{trJ or olIE.d lor ele (se ?o44, B$inN ed Poasiods Cod.: lnc Contodor s l.iclM l-a$ doc nor apply to u oM6 ol
<br />rh€pmF1y wno hril& or impro\ 6 th6en. ed $ho dG $ch sork hirns.lf o. h.*lf o, rhtough his or bd o\h dplor.6.
<br />prolid.dlhd such inrprovmls e not inloded or ott6.d nrr slc. I r. ho$66. rh. trildir8 or in!rcvffin is $U wnhin on. ya
<br />ofcompl€rion. rhc OMd Buills *iII hr!. lhc buda ollrovin* rld h. or shc did nol hild or inlp6( lhc prorclt for thc pur?oE ol
<br />_1, s oMd of lh. piop€ly. m cxclusiv.ly conlractins sith licas€d conrr&ro6ro @isdcr th. poj.n (S(. ?04,1, B6i!6
<br />a.d hotusion Codc: Tfi.contidor's Lic.n* Lrw do6 nor,pply to o ownd olpmpcnywho buil<L or imprevcs lhson.
<br />.nd who contEls aor suct projccrs wirh s ContBclo(, licm.d puBuer r thcConlr.clois Lic.nsc L!w).
<br />I dn cxenpl undq S<tion-. a &PC lorfik r6on
<br />rr(2a[EErtco!!&!s -uQ!IIQ4IAIIAB
<br />I l'6.bt amnn !nda'pdahy oapejuryo"colthe lolkNins deluatioD!:
<br />I hav. aln Nill naintai! a Cdrificare ol cotudr ro scla lBd. for workEi con,p..salio., 6 rr. dtd inbtsdiooI700oflh€
<br />hbor Code. for thc p6aom cc ol lh. vork lo. "tich rhe pmi 6 isru.d
<br />I havc and Nill nBinrain workerr conpcBalion istrBncc, s rcqoned b] S<lion I700 of lh€ l ztnr Codc, lor rhc tsfomdc. o f
<br />the \york for $hich rhis ponn i. i*u.d My portcn comrserioo iNumce catrig ud Flicy nunbcr d.:
<br />LO
<br />10 \2 -\(-ra
<br />-l.diayrhd
<br />inrh€ Fforoarcc olthc qork for which thh p€mit ir isued,I shall.or.nploy any pqson in ymmod
<br />s 6 lo b..om. subjat lo lhe wortsa onp.ns'lion la$ ofcolifomia, and aer thal il I should b.totric subjd lo th.
<br />work6 comFelion pmvi.io6 olsftio. 1700 of th. bbor Cod.. I slEll. tonhwith coryly vilh lhoei,rovisioB
<br />WARNINC: Failurc lo Bm workd' drnF&tion cor@gc is unl0wtul. Md shalt subjdi o oplqE to dif,lntl !aitti.. ed
<br />civil fin6 up ro one hundEd thousd doll6 ($100,000), in 6ddnion b lte con ofcompdslion, ddasd d ptovid.d lor lh.
<br />Sdion 1076 ofllE Labor C.dr. i.r66r dd.tiorruy s 16
<br />rion,:bz n^E_rao( €- L \
<br />llcEls!:p-caNrlacroB
<br />DECLAAAIIO!
<br />I h*cby alrm u.dd p.naky oa p6ju,y thal I m licos€J undd lxrvilion ofChafld 9 (coohdcine Nilh sdion 7000) olOivision I
<br />ol rh. Bcin* dd Ptul6ioB Cod.. md ny licfisc is in full forcc od efi(t.
<br />, 'A qClO L\Az Li.c6eNu,h.r - ?, ?9-l n
<br />{tr t3-tg (onrr.c,or E -h4.,E+P-< E-LL
<br />caNsralcuaN.LExDlNcacExcr
<br />I hd.b, amnn ondd p..ahy of pcdury lhal thd. is a coNlruction l€ndin-! asdcy lor lh. FaoLlmc. olln wrt lor \hich rht pdrir is
<br />i$u.d {sd 1097, civ c )
<br />AITUTANLDICI,A.BAUqtr
<br />I hdby allm !od$ poahy ol pdjrry o.c oi the follosir8 delmariofls:
<br />Ddolirio. P@is Asbdros Norificarion F.ddal R+ulalions (Ink40, Pan6)
<br />Rctuitu{ t lrdof Noiiolion
<br />-l
<br />cdirythal lhe ledcral re8uh ions Esddi val dc nor appli.ahlc to rhis uoj
<br />l.dri! $d I lr\.rsd rhisapplicario ion t corc.r I alId ro.onpl! wnh allCilyand County
<br />ordina.cs md sror. Lr$s rcl,ril8 to bu iv6oarnisCity d Counlylo ols UFDlhc
<br />a&tr€ nrcnlioned p'!p€n) ld
<br />ApDlicn r o' .\!ttrl sistr,r '.,,,"-,1- l3
<br />oe )@-
<br />E
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Fram inq
<br />lns u lation/Energ y
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />IA
<br />FINAL 5-2J-11 vwLln
<br />Certificate of Occupancy uv
<br />Notes, Remarks, Etc
<br />-+
<br />BUILDING. INSPECTOR RECORD
<br />T-Bar
<br />Flood Zone Certif.
<br />,",", - l\- I ?- rt,
<br />tf,ndersNrme _
<br />L
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