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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG-OWNF,R IIUILDIR DEI ( ARATIO\ I hd€by .rm undd pcnalry ol p€rjury lhal I on qen,pr fitrn rh. L'onrr0chE' L(en\e I a( ror Ih. iolloMng rcdon (Sc.?011.5 Busin6s d Plol6sion Code): Ahy Ciry or Counry \ehicn r.quir6 tr pqnn to .otrsrrud. all6, improv€, d€molish ot rcpat d] 1r,!ctue. rior ro irs i$uam, also rotunB the applic&l lor strch p.n.i lo frl. a 3i8n d s,lmMr thar hc or shc is licd*d punuanr lo lh€ prolisions ofthe Contriclois Licensd La$ (chafler 9. Com.nci.s with Sdion ?000 of Division I oflh. Busin.s ud Prof6sions Cod€l or thar hc or sh.6.rmpr thfr.from md th. bsis for lhc alltg.d €rmprion An, violation ols€.1nn 70ll 5 by any spl)licanr forapmn rubjdts rh. rpplicad lo acivilpcnaltyolnot mor.lhd firc hundreddolla6l1500). l.soNn6oirhcprepcny.orDy.otlorGwnh$ag66rh.neEmmp.Nrion.filldorh.$orlddthtstruclrcisnt' intdrldl or of.r.d for el. (Sc 7014. uusins md Prcldioos Cod.: l hc ( onlra.toi s LicN LaN do6 nol apply o d oMer oa lhc FlFty rho builds or ioFov6 thNn, ad who doe $(h $d( hiNself or hs*lf o' 'hrouBh his or hd own cmnloy.6, prcvi'lcd rhal such inprevods E mt inlqd.rl or ofir.d fr elc lr. ho{. d. the b(rildins or imFo\ dn€d is sld sirhin on. }a ofco,npldion.th.o$neralild(NillhalclhcbrdorolEovinstlElheor5h.didmrb{ildotinlmvclncpmpdrrorrhepurr.sor, I. sown6oath.propqly. m.xclusiv€ly contradins virh licc6.d corkacroE to cotrnruct lh. proj.o (Sa. ?044. BGi.e d PFission Cod.: Thc ContEdo.s Lic.6e Low do6 nor apply lo e ovn$ olprop.ny who builds o. imr.o!€s lhd@n, and \rho enrmcls lor such ptujec $nh a Contmdo(, lic.N.d puE@t ro lhc conttdors Lic6* rjq) I an cr€mpt undcr Sdl ]roB[EEs:ca![!ttaI9! D!!!ABr!!!A! I herehy rfli'rtrndq psdtyolpLl,"r_otr olrhc nnkNir! d.ilararions I ha!. d Nill mainlain a a.nificarc oaco@nr ro S.lf lBUrc for &rtra conp.n3tiion, d pbvid.d fot by SEI ion l'700 o t $c Labor codc, for rh. pdfonnec. ollhc wort for rtich lhc lsnil is isu.d. ,lhav.and{illhaimainwolkeccornp.nsolioninsuronc.,srcqunedbys*rionlT0ooftheLabotCodc,torlh.pdfonnonc.ol lh€ sork aor $hich rhis pennn is isrcd. My workgr .oflrpoMtion insurMc. cris ed tiolicy numb6 rc: :t*sF ..nifylhd inrlrp.doflnanc.ofthc$ork ior wh,ch this pcmir is is$en.I shallnol cDpkry atryp.Ron in.nymanns ro h€comc subjd ro lh. soA6' comp.Nation l.ws of Caliaomia. ud asrc lhar il I sho,ld b.<o'n€ subid Io rhe wo*d' @topsalion prorisioB of Scclion 1?00 of the I !h.ll, fodh{nhcoflply \viih thos Fovisiotu \rlRNlN(; I.ailure n, scurr \rorlds comF.sarion unL\vful. md shall subjer onploycr ro qhin.l ps.hi6 dd ion. ddas6 s prolid.d for thecnil find trp k, od. hund..d lhous'l dollds ($1 s$r n:1076.frhcktoicodc. inltrd d a(orev s t- I heby artr,n u.d( p.n.lry o f psju,y th,t I an (commcn.ing \irh s{lnln 7000) oiDivis n l lr'Lqb, 'a-.i1 S Co A o c-.i1o/.) CANSIBIJCUAT'EIDIIGACINII I hd'by amnn !nd6 p€.ahy of p.Uury lh.l ths. is . ooslrudbn Lndin8 agdcy lot lhc Flimdc. .l rh€ work lor vhich tht prnrn n issued (s6.3097, civ. c ) AITU(ANLDICIASAIIQ! I ho*yamnn under !.natr, olp.lury on. oflhc followin,! d(l alions: Demoliliotr Pe'mils-Asbeslos Nor'licarion F.deral R.guhnrds (I nl. 40. l'd6) -R.qxt€d lxrtq of Nolifi cabn trsr+Ed''u astf,\hs u o\.1^'c trfr^Dpll.ahle k,lhs F'oj(r sarcrld lltrrhvc nrlonnalion is co'rc.r I lgrdro conrplyvith all cnyand counry dl h+bv ad hnrEc r.!r6drn /n^'- iv6 ofdris cnved Counry$.nta umn rhc abov. $.nrion d pr.$d! aor \pprtrnr or agenr slgmrrrc:lt- | , l'( ,n( rn'c(Irid)l tA-L ^'* I Set Backs Erection Pads U FER Ground SLAB Floor Subf loor/VenUl nsulation Roof Sheathing Shear Wall Framing lnsulation/Energy Dry/vall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif L\\ FINAL +-7.-t'"1 Y-V-hA Certificate of Occu n Notes, Remarks, Etc COMMENTS Forms/Steel/Holdowns K',.,l\- \ Ir (4J.16\ _ --------T------ I