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BUILDING- INSPECTOR RECORD SITE-WORK ID/SIG.COMMENTS OWNIJR BUII,Df, R DELCARA'TION I hdcb, amnn ondd pcmlly ol p€rjury $ar I m .\€mpr ton rhc conr,cloa' Lic.nsc Lis for Ihc rollovin! rcen (9..?0ll.t Eusinss md l"ofsion Cqlc) An, aity ot Counly shrch r€q!i'6 a pnnir to co6rrucl, illd, nnprove. dcmolth or r.pat anv srruduq rrior ro ns isodce als rcqur6 rhc applicanr aor such p.mit lo fi1. a silnd sraroHl rh.t hc o' slt b li.m*d puB l lo rltr provsions ol rh. Conlraclois Lic.lsd Lar (Chapler 9, Cornben.inS vilh S.clion 7000 of Division I oflhc alsines md ProlcsDns Code) or rhar h. or shc ir .xcmpl lhgelion dd lhe b.sis lor rhc alles.d etdnprion An! violalionofs..ri6n 70115 bvanv applica lor. pennit sobjsls rhc applic.ntlo acivilpoaklol'not morelhu liv€ hundrcd dollds ($500). l. 6 osnq oflhc p.op€ny. o ny cnlploye rirh was6 6 rhen sh .omlerealion. {ill do lh. {orl dd th. slod@ is .or inrddql or ofid.d lor s.L (Sd 7Ol!. ltusin* a.d Pronssiotu ( od.: I h. contdols Lic.N h$ do6 not applv io an owod ol rhe propdy tr ho buil& or in roc th6&n. ed who dc $ch *o* hinselaor i6ell or rhroulh his or ner orr dplot.e. r/ovid.d rhar such inpmrdmrs enor i ar&l orolIdai ioreh.lr, ho{dd, th. buildinA or inl,or@6r is eld wilhin on. }@ ofcomplerio[ rh. Osrd Btrildr siu h.w thc budo ol pdins rhat hc or she dij nol hrild or inprorc tfi€ Fopdv ao, tc purlIs of l. d orns of rhc Fopdt, an crclusively conl4din! *nh licmsd conlraclo6 ro coNrtud th€ roi.cl (Sd 7Or4. Bltrins and PiDasiro Code l he Cotrtrrcrol s Licctu. Lsw doB nol apply lo d o$nn of p!op61y * ho builds or nnprcv.s $d.od. and *ho cohrhds for such projeft wnh a Co.lsclo(s) li.ns€d pu&anl lo rhe('onlmclois L,icds. Li*J I E,D.\an.r nndd Sdrnn .B & P C. fo, rhl"dun lt.le: Orn.r: TVORKERi...NIPENSAI ON DDCIAtsAIIA! I hdeby afilnn undd pmaltyotpdjuryoncoarhc follo*in-! dclaatbG: I havc dd *ill man ain . Cslificalc olcocdl lo s.lf IGm tor \orkc4' .onrpdlation, s pmridcd lor bv selio. l70() of th. kl,or Code for rhe pdfoman.. of lhc soli fo, Nhich thc p@ir i! issu.J. -lhrv.andsillm.inlainxorl.s coftp..satio. isorancc. s rcquted bl Serion lT0O ofthc lib()r Cod. aor lhc psfon.dc. oa lh. work for whicn rhls p6nil is Nlcd My wolkgt comp.Ntion iBuroc. cmi6 sd policy nudb6 de: I.dlilylhar ifllhcD€.fo@n.eolrh.Notk lorrvhi(hlhis p€.lnir ir issudl.l shall nol d.ployanyp.son in anvmdnd so 6 lo headc $bj(r ro rhe work6' compcneltun la*s .ic.liiomia. ud asr< lhar if I should be.on subld lo thc *o,k6.o6p.Nrionprcvisio6ors.ctionr?00ofIhcLiborCodeIstDll.lonhwnh.ofliplyuirhth6epovisions. W RNTNC: tnibrc ro s4 r. rvolksl compc.urion covd8c is unla$,ul. Md $all subjd u 6.plord fu 6ihi.il laatie md civil nn* up io on. hundr.d tho6dd dollm ($100.000). in.ddnio.ld rhc cosl olcomp€el i(n,. dtun.tes as t( id.{ lnr ihc Ss.rnr :1076 !l rh. Lnlar (ndc.d,r*a atgdlAllol I hdrby .ilinn unds pqaly o I Fdjry I licds€d und6 prori.ion ofChaplq 9 (coto!n6.ing $nh S.clion 7000) olDi!isio.l ol rh. ausinss md l'rolessioN Codc, dd,nyli.croc is in full lorce dd.fli.r C\O C L(S u(L(61b \2S S \€S I hen6y .mi!n nndq pcmhy ol rdjury ,sru.d (S< 1097, ( iv C.). nsrrudion kodins 0Bdcy io! the psaom@c€ olrh€ sork lor $hi.h thG psrh is APPI ICAN T}'CLARATION I hE ny aflim undq poalry ot pdjuy one of lh€ tollowi.s d€larar ions D.nDlition Ps,nils-Asbdtos Noliiic,l ion l_.dsal Rcsulalions(T lc'10, Pan6) Requncd L.lls of NorifLarion are nor appl'.abl. ro rnis pmjdr iomarion is cotrcr I asrE ro .ornply Nilh all Cny ud Cou.ry aurho.izc reprenlal iv6 o llhis City md County lo dr6 ulrh lh€ /71) tL dl Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subfloor/VenVlnsulation Roof Sheathinq Shear Wall Framing lnsu lation/Energ y Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif FINAL f[ t"t\r:.Ultr4/tE. Certificate of Occupancy Notes, Remarks, Etc. DATE Set Backs //-tq-lv U ""-"-Ku: