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BUILDING- INSPECTOR RECORD SITE-WORK DATE rD/srG.COMMENTS OWNER BI]II-DER DEL('A II 'TION I hdcby amnn unds poally of pdjur) lhar I sn.r.nrpt lrom llrc Conirtclols' Licensc Lae lor Ihc follo*in! rmn (Sc.?011.5 ts6in6s and Prolddn Code): ny Cily or County $hich r€qui6 a pcf,nn b codrucr. ah6. inprovc, d.nrlnh o! iepan v $uctuc piior o ils isu .c, .ho requte thc arplicol aor such peflnit Io file a sisned ualendr thit hc or shc is licdsd pusudi lo lhc Foviqiod of ih. codkaclois l-iccrsd lis (Chaprr L Conmcncins $nh Sclion 7000 of Diriion I ollhc B'6in.s &d lrclGsioos Codc)orlha( heorsh. is.ranpl thdclrom d the b6is ror thc illq.d ex.mption Any violaiionols.clion 7011.5 bvanv applica for a Dmit subjcb lhe arplicanr b a .ivil p.nahy ol tor noE thu liv€ hun&.d dollare { 1500) -1, s o{ner oaibe pmpedy. or my dnplo)€6 \vilh Bas6 6 thetr $le comp.Notion. $ill do lh. No* dd $c sMm G mt i ddel or Df.red for hlc I 56.704.1. Busin6s and tlot*sbns Codc The Coniracroi s t,icase lls do€ nol @pl! to an own6 oa rfu IioIEty wh. builde or iq,ro!6 th66n. dd \!ho do6 such \wrk hims.lr or hs*l f or rhrough his or hd oen cmployc6. prolid.d rhar sxch improvdcms m nor imdddl or ofad tot slc. l( ho{sd. lhc bnildinS or i,nDrovft.n is ekl wittin one Jq oflld9lsion. thc Osrd adtlc will havc lh. brlrdo olrmvios rha h. or sh. did nol hlild or impre\! $c prllEly fn lhe purpoF ol I. N o"rr oathe Fopsl), @ €xclBively coturadin8 wnh licd.d aol,aclo^ ro cod'ld rh. p!j.d {Se ?o44, aGme and Pnrtsion Cod.: Th.Conlraclois Lic.nsc l-arv do6.or atpl, b m own6 olprcp€nyvho builds or imprcv.s thqon, md who conrEcls lor such proj..15 {ifi r Coninio(s) licaN.d puGuant to the Contra.loas Lic.e La*, I m.xand und6 Sarm ,B &PC forrhErNn D.rer Orrcr: ]EOA!!EBS!A!ItE!! IIIN DI'(IABAIIO! I nscby amm undq pddr, ol pdju.y on. ofrh. follovins dElealio6: I ha!. d sill mainrnn a Ccdificar. olcoMt to s.lf-lnsure lor worl.B comp.nsliion, s Fo dcd for by sdion 1700 oa$. bbor Codc. for rfi€ pdfonnaDce of rhc *ork fot whi.h rhc Fnit is isued. Ih.vcandsillmainrain*ork€6compdMrioninsur.nce,srequnedhyS{rion.l?00ofihcl-aborCodc.aorlhcpdlo,inan.ol rh€worklorwhichthirpd.ili.issu.dMyxortmcomp€Nario!iNur.ccnidmdpolicytrunrbsa€ x."" -l cdilythal nrlfi€p€rfonn.nccoflhcworl for whi.hthh prmil is isucd.l shall nor ebllotanypecon rn any'ne.e s 6 kr bcomc subjd r. rh. sollcs co'nFs0lion lass ot CalifoDia, md a!@ rhat if I should bsom. subjd ro rhc wor k6J co'npeertrn prorisioN ol Sdion 1700 of lhc lihor Codc, I shall. ronhNith comply wilh lho* povisions. \IARNING: Failure io suc work6 codFnerion .ovd.se is rtrlo*|trI. d shau strbj..r d lioys lo ohi.al ldExi6 &d , n'l finrs dp r. onc \unded rhousdd dnlld (tl0o.0{,{,. sarion 1076.frhe Lstnr Cod.. ri.r6r md.xomct s fs. n' addnion ro rhe co$ .l [4*. DICIA8AIIA! I hscby a,Im und6 ,oall, oa pdjury rnar I tun licss.d und6 rrorision of ( haptd I (comnmcins Nith Sdio. 7uJ0) of Division 3 oa thc Busin6s &d Pof6ioc Code, dd my li.ms. is in full forcc d €{I€cl K,tL 26 u c Y.^,/9Ut^;+ra€ae[ caNslaucuax!:ll)nllcfN(r I hseby alIm u.der F,alry ot p€.jury lhd lhec 6 a cotr{tudio. lcndins asdcy tur rh. Pdaommc. olrhc sort lor whi.h rhis Fmh !i issu.rl(se 1097. civ c ) AEUTANL.DECIAEAIPN I holby amm undd poalryoaprjoryonc ofthc followins d(ldalion!: Dc'noh ioo Pm s A3b6ro! Norifrarion F€ddal R.rulalions (Tnle 40, Pd6) R€quned Lard of Notiti.{ion I cdlify rh0l rhe tcdsal rcrularioB rcgedin8 sbsros rmrval uc nor applicabL b rhG Projd $al I hde r€d rhis applicrtion a'd slst. lhal th€ atnve i.aomarhn is cor€1. I ssrr lo coiply *ilh all City aod Counly ordinnnc6 and Srdlc I-a*srclari.s to abolc morioned rrcpsry toi i6t..1 p0li.ant or AEml SiBnal X,," Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subf loor/VenVlnsulation Roof Sheathing Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif FINAL 6-5"v.v+)d Certificate of Occupancy Notes, Remarks, Etc {8 Lcrdd'3 Add6i-