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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.OWNIiR SUII,DER DELCARAI]ON <br />I hdeby aftrrn undd perah) of tdju! lhd I en .rc'npr lsm rh. (onlracroB' Lic.ns. Law lot the follorvirr! r.Mn {Sa.?0.11.5 <br />srsih6s anrl Prol6si0. Cod€): Any Cily or Counly {hi.h rlqut6 a ponir ro .oNtruct. all6, nnprov.. dqnolish or ripan v <br />slruclue, rrior to il! isumcc. also r.qut6 rhc agplicdt lor such Fm to fil€ s siSacd slar.md rh.l h. ot shc ir li<ds.d p6uel <br />ro rlE provisioN ol lhe Conrrocrois t,ic.ns.d lj\' (Chlrre 9, Com,nen inr wnh Salioo 7000 of Division I otlhe BBinG &d <br />Poisions Code) or rhar h. or shc is excmpl rhserron ed rhe bdis lor lhc allcg.d erdnlrion Anv violirionotS..lion 7011.5 bvan, <br />applt,rlorapmirsubjeclslhcapDli.adtlotcivilp.nallyofnotmotelhdnv.hun&.ddollds(1t00) <br />l. s oqs oflhe pmFny. or my cmplo)G $nh wa86 s rhen eL conp.nsslion, Nill do lhc trotk dd lhe sr*tr t mt <br />inrd&l orolra.d ao; sl. rsd.?044. BBins d Prclsn B cods Tnc contractol s Licos. lis do6 nor gpplv to e ov do' <br />lhe pm!.sly sho b!il& or nnpmv6lh@( aid *ho dG sucfi wo& him.lf or hdlrorihrcush his or hd o*n cmPlov€d. <br />prcvid.d rhar srh impmvoftils @ mt L 6&d or otIJqj loi sk ll fiow6 6. thc building or inprovddn is $U rnhin on€ r@ <br />;acompl.rion, lh. Osnd Blilda will ha!€ lhc htdn of poring thar hc or she dd nol bnild or nnFo* Ue PDFrv lor $c O4oe of <br />-1. <br />6 oM6 oflh€ prcpsly, an .rclusiv.ly coolnclinB *ilh lichs€d conlracrou to co6trucl lh. Fold (Scc 7044. B$ins <br />ard PDfsir.Cod.: Th.Conlradofs Lictue La* do6 nol applyro o$n.r ofprop.nv{ho builds or impro!6lhrNo. <br />eod who co Eds for su.h trojd8 wifi 0 ContEclo(s) li.oscl Pu6oanl lo rh. Conlrrclois Licm. L2w) <br />I tun.r€,nd und6 Sdn,n-, B &P( aor'hisre6on. <br />IVORKI,RS' COMPENSATION <br />DEC.LAEAIIO! <br />I hqeby amm mdd p4alry olpdjuryon.oalhc followi.s d(ldarioG: <br />-l <br />ha( a,rl will moiniain a Cdificalc of aoosdl lo Selt-losurc tu vorkcs @nlPo..lioa. s prcvidcd tot bv Sation 1700 otrh. <br />Labor Codc, for lh. pqfomnce ot lhc sorl foi shich th. pqmit t a3u.d <br />rcqun€d bySe.lion 170{ oflne libor ( odc. for lhc pafonnd(e of <br />ion insurdc. cdi.r 6.d tnlicy nnnha mI Iarcand willmainr!in Lvorkc( .onrFnsar <br />rh. \.rk tur Nhich rh6 pennir is issucd. My <br />I cdr&rn.t in th€ perlomance of rh.it for whichlhis p.mn isissu€d.l shau not anployaoyP.6on in anv mannq <br />s 6 lo b..o,n€ subJer to thc so.l6 conpo:Mr io6laws ofCalifomia, and aBE th.t itl should tE om.subjd to rh. <br />so 6' compoelion pmvisions of S.dion 3700 oarh. Lab.r Codc. I shall. aonhwilh <br />WARNINC: Ir.ilurc lo sue work6 .o,npcneliln corsase ii unlarv <br />civil tines up lo onc fiun&.d rhoused dolla^ (n. ddn.tcs 6 provid.d ior rh. <br />Sdrion 1076 olthc libor (ird(-t4 <br />I d liccnsd undd Drovision ofch.pts 9 (commd(ins q nh S&1ion 7000) oaDivtion lI h. by €.lrundn poalry o f |Erj <br />t 02?-L3y <br />I n*by amnn undr paulry of poju,y rt ur rla is rmio,, tddins a8oc, for th. psfodec. of rhc {ort for *ii'h rhis pdnil i! <br />issu.d (Sd. 1097. Civ. C.). <br />I cn,ld's Nrme <br />- <br />Len'ier ! AdtL6. <br />AIELICANLDECI,AEAIIOtr <br />I h6tby aflim uod( p60lly of pdjury on. olrh. follo$in8 d(ldalions: <br />D.holnion Pfl,ils'Asb6tos Notificalion F€d.61 R.sularioB (lnle {. Pan6) <br />-R<uir.{j <br />lill6 of Norifiqtion <br />-l <br />c6lilyrlh rhc ledsal rcsulalioro r.8edin8 sb6Ios reno\al,tc nol spplicable lo lhis projd <br />I c.iily rlrd I hi!. rqd this amli.ar <br />ordi.tu.6 md stale t ws <br />ab.vc !rcnrionql rmpdy fo! i <br />,\pplicntrr or Asdr SiA rl <br />ion is cotr*r I rlrdtocomplyw hallCn,and Coutrly <br />rpc renr6ota,^6 olrhis C ) dd cuunr, h ors ulign th. <br />I; il-tq'tL <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVlnsulation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />ln su latio n/Ene rgy <br />Drywall <br />Brown Coat <br />lrla so n ry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL lllL4/t(t ,a* <br />Notes, Remarks, Etc. <br />COMMENTS <br />Ext./lnt. Lath <br />an unploys to oinriral FElti6 and <br />of rh. Busins and Pref6siotu cod., dd my lic.n* n in rull forc. ud elTcr <br />1 1Lr <br />) <br />,?z