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SITE-WORK ID/SIG.COMMENTS OWNEII BUI I,DER DET,CAR-{'IION I hreby alliirn undr p.nahy oa pdjury rhar I m cr !n amd rhc Conrr0clom l,,c.nsc l.av for rhc follo$ins ,@)n (s( 70:l l 5 Liusin6s od Profsion Codc) Any City or Counlv ruhich r.qut6 a p<m'l lo codnct. alrc. improrc dmolish or rqin m) sttudu.. 116r rd ns isudc., ale requiB rnc amli.d lor su.h penn ro flc a siBncd srat.mmt lhol h€ or shc is liccB.d tmumr lo lh€ provisiotrs ol lhe Contidoas Licensed lav (Chaprs 9, Con.rn.r.B rnh Sdion 70010 of Dirision 1 ol rh. Busin6s ad Pn)fcsn rs &'d.).r rhar hc o, shc is cic,npt ihcclroD and thc bsis for rh. alles€d crcmplion Any violalionorsdiofl 70115 brany applicant forapmnit subrats lhe applicanl ro.civilpenahyofnol morcrh [\.hundleddolles($5Ls] -1, 6 ouncr ohh. F)pcny. o ny enDloy.6 *irh w,ss s then solc coDp.ns.t ion. s ill do th€ \ orl d lne slruduc n not inrsxlel or of.red for slc ISc.70.14. Busins and Proasions Cod€ 'l h€ codta.tof s Li.ssc La{ do6 nor applr Io an o\ nr or rhc Drold1y \rho h'il& or impro!6 tlEon. ad who doe sucn m* himsellor hos.lfor thrcush his or hd osn drpl.yc6. prolidedlhat such io!.ovoEds 6r mr idddcd 6r olIdsl ror slc. IL ho(a a. rhc hrildin8 or imp.or qnenl is $kl $irhin onc )d ofcobplLlion. the on.d Builda will h,vc lhe hndd ofpiovn$ lh, h. or slrc did nol hrild or i'np!v. thc preFil for th. purpoE of l. asorvndolrh.rop€rly, dn cxclusl vcly cont nd ins $irh liccns.d t.nta.roaroconsrrud rhe rroj€r (S4 7044, aBnN ard Psfs6. Codc'Tnc Conlraclor5l,icens. Latr do6 nol.pply to an o\ncr orpropdy \ h. builds or nnpro\cs lhrNn. and *ho conlrrk lor such FoJ.lrs *'nh a Contacro(s) liros.d puu@r ro rhcConlrlclois Licensc L.rv). -l an cxempl undtr S€cl io!-. B & P.C. lor rhis r.6on Dr(. Orner tlaa8&Blt cl)!l8E!rar!aN DECIA.B{IIO! I lEcby amrm undd !.nanyoapdjuryoncof rh. lollorvinB deld.rioB -lharc d $ill maiman a Cdi6.ar. ol coNdr ro sctal Bur. Lr \vorke6 cof,p.nsir 'on, N l,olidcd Ir by sdrn,n :1700 oarh. l,bor Code tor lh€ psroma!.c orlh€ \yoik t)r Nhrch rhe p6nil it i!su.{j I h,v. md will m.inraid lv.rk..r comDdtsarion iruuranc., s rcquts] by S6rion l?00 ol lhc libor Codc, aor rhc pafomdc. of nr work for which lhG p.mn is isued. My work.tr cor!.reation i6uranc. cnis ud policy nunbd del Poliry Nu'nb.r lirpirls I ccnirylhal in rhe p.rlolmncc orthe rvork ror Nhich this ri€rmn is $sudl.l shallnor dnplo, tn! pssn in..) munq e ei ro b..oD. subjed ro rhc work6' comp.Nation laws or Calilomi.. ad isle lhal ir I should b..om. subjd' ro 'hc$oltss conrposrionlrcvisionsolS$lion 1?00 oilh€ libor Cod€. I snall. fod*irh .omrl, $irnrhos Eovisions. wAnNlNCr Fdlurc ro suc worlc6'.omp.6arion corem!. t unla$aul. ed shall subjet mploy.! to oi,ninrl poahiG a civil nn.s up xr on€ hrndr.d rhoutud doll6 {$100.000). in addnion ro tlE osl oi conD.nsrion- doar6 6 prorid€J a.r rh. :(\1r'n 10_o.tlrh. tihl c^de. inr.'d rd anun'c' 5 rG apt ienr: LlcENSlLCQtrrSACrAA D}:CtdrAllor rhal Iom licmscd utrdLy pro\istunoichaprr9(cotu cncinswiihSccllon7000)ofDivisionlI hd.byrmfrutrdd r.mlrvol of ihe llusines 0d Pr.( odc. dd nrylicure is h full for.c.nd elTLti ?{3 u^"//'2aI I hseby .lltrm und6 penalty of pdjury that ths€ is a consrrudior lardins as.n.y for $c polonndcc olrh. work lor Ntich Ihis p6ni b iss!.d (s.c. .1097, Civ C ) JIE TCANfDECIAAAIIO! I My afiinn r.dd penahy of p.rjuy onc of lhe folloqiu d(larorrcnsl Dmolilion Prmi's-Ash6los Norilicarion r€dcral Re8ularions (TnE 40. Pan6) Rcquired t!r.r olNoti6calion 6b6r$ ronor al &c nor ,pfli..bl. ro rhis t)lojNi nd laarero compl, \rirh all( iryand ( ou.r, dnesolrht C(y dc.unrrb.md u|Bn E ,lrplicatrl or .\g.nl Sianrturc J I 1. )_o/) Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subf loor/VenVlnsulation Roof Sheathin s a b//t O^tot*/04, Shear Wall Framing ln s u lation/Energ y Drywall Ext./lnt. Lath Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif FINAL ////r//t- |Vt+*zz-/cz-- Certificate of Occupancy Notes, Remarks, Etc BUILDING- INSPECTOR RECORD DATE Brown Coat 14