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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.OWNER BUILDER DEL('ARATION
<br />I h6.by amln und€r rE ally ol p.rjury lhal I m erempl frorn lhe Contacrors' Licen* l-arv lo! rhe followins r.M..,sN.7031j
<br />Busin$s and Pror6ion Codc): Any Cny or Counry *hich requn6 a pennir ro consttu.i. alt6. i'nprolc, dmolish or lcriir )
<br />srruduc, prior lo ns iso&.e, also r.quir6 rhc appli.d' lor slch p.mn lo 6lc a sieicd staran I rnar h€ or shc b lics.d puBuer
<br />lo rh. lrorilionq oirhc Connicb.s Liens.d l-av {Chaprd 9. Comdcing wi$ S(rion ?000 oaDivision :l ofthc Business ond
<br />PlofsionsCode)oitharh.orsh.isct.,nptthGcaroomdrh.bdisaorrh.all.sed.xmprion.Anyliolarionofs.clionT0llSbymy
<br />applicol to! a p.mil subj(Islhc applicaflr lo acivilpcn,hyofnoi mor.lhan fiv€hundEddollas($5($)
<br />,2Q. s ownr orrirc pmpeny. or my €mployB *irh w,s6 B (heir sle comFMio.. $ ill .lo $e sork md llr slruclrc is nol
<br />inradsj or ollded for elc (SE.?044. BuiDs sd PmfsioB Code Th€ Conti.iof s Licosc l,w do6 nor ,pply ro m o$6d ol
<br />rh€ rioFry *ho b(itkor impmvdrlEotr a.d $ho dc .h sort him.lf or h#lf or rh ou8h nis or hd oNn cmplor.6-
<br />proridcdrhrr such ill'o\Edl.l E mr inrod.d or oltscd tu, slc. li h.{86- rh. trildbs or i,worl]1d ir $kl wirhin on€ rd
<br />olcompkiotr th. (nrd Builllr "ill hnrc fie Ufl6l ofpmli,g tnd h. or sn dil nor build or imFlvc thc prtrpsly lor rhc pitrpoeof
<br />-l.6orw6of
<br />th€ Fop6ty, oncx.losivclyco mcliq wnh [c.c.d codrocro6lo.onsruct lh€ projsl (Sa 704t, BB'.4
<br />and Psision Cod.r Th.Conlnclo.'s Lic.ns. Law do6.or apply ro d oNnr oapropdy vho builds or improvelhson,
<br />nnd $ho conhcls for such proicls Ni'h a Cont
<br />I dn.xenrp' und€r Sd
<br />o,,.,/ /- 5 - Z o1l8
<br />""".,,
<br />I hcrcby aflnm undcr p.nahy o I psjury one ol t
<br />lo S.ll'l6ure for worl6. conrp..erio., 6 Foid.d for by Serion 1700 ofih.I have ud $1ll Finrain a Ccnificate of
<br />&t{rr Codc. for rhe pdaonnecc oflhc Nork lor vtich lhe pdmn is iso.n.
<br />I havc and will m.inrrih worterr co.rp.Bari.n insur.n.e, a rcqoir.d by Sdion 1700 of lh. t bor Codc. lor lhc psfomac. of
<br />rh€ rork aor which thir ptmil is isucd. M, workeB comFroalio. i6ur cc cni€r od policy numbd &.
<br />-l
<br />ccnifythai inlhepobrmaoccofth.{oik lor whichthisprmil is issu.d.l shall nol onployanyptuon in tmmitr
<br />s 6 ro be.o,nc slbjdt ro th. wo, km' .oDpsd ion ldws oacaliaomia, md agree lhal it I should bcco,n€ suhjct ro rhc
<br />Nolt6' conrposation pruvisions ot S.ction l7L{ of the L.bor Code, I shall. fonhNiln onrply with lhoF povisio$
<br />W]\lt:,'llN(; l:rLltr'c lr) q.r'. \o'1.'J cout)cD\ilknr
<br />r IL Lnrrs , p t) on. l,trnd,crl thousrnd doll s (1100.
<br />is unl!$ln|. and sha]l subier 6n onpbyd lo dninri pemhi6 ond
<br />ion. dana8€s 6 provid€d lor th€
<br />Sc.rdr :1076olrhc Inhtr Qrdc i .'c(andartonrv s
<br />o"", //- 5 - ZolF n
<br />I hd.lJr alfi' ru d< ahloltdjryr[ laDli
<br />of ihc Inrmss md Pr.f6so,s(ide dmvl'c
<br />S(rion 7CO0J oflrrisio. I
<br />CAX$AUCI]ANIEIDIIiC.ACEICI
<br />I hqcl,, amr6 und6 Follry oa Fjury lhal rhdc a a @Nruclion ledins ara.r for rh. Ffommce ofrh. work aor shich lhis p6mn b
<br />isucd (s4.1097, ci!. c.)
<br />AfILICANIDICI.AEAIIO!
<br />I hdd, aJrm unda pdaltt of pdjory onc of th. lollowins ddl@lions:
<br />Dcn{hn,n Psnnrs-Asb6ros Nolin&rion F.d@l R€gularions (Tirl€ 40. Pan6)
<br />R.atrtrrd I c croiNorifilal(r
<br />-l
<br />cenily thal rhe ledcral rcgulario6 r+ddint atEsbs rdovalde nol applicablc Io rtis prerel.
<br />+cglify rhar I havc 'dd rhr sprilicarioi lonnarion i5 cod(r I agre b .onrpl, $irh all City ..d County
<br />o inancd dSrar.I!trsrchrinsio bu ho,izc rcpr66rariv6 oafii! cn, ed co[tyto 6'q uIIn thc
<br />above r.entiotr€J prop.ny aor iGpc.l
<br /> pplicrnl or Ag€nl Signilurr o"",11:5:2o/]
<br />Set Backs 7 a
<br />Forms/Steel/Holdowns 7 7 ,JIIL'J ngb{r2l)^)lt,l A
<br />UFER Ground /,01 \yr
<br />SLAB Floor
<br />Subfloor/VenUl nsulation E1l6'\ltt^w0d )
<br />Roof Sheathins /Z;7; .,Jh".l)\J..
<br />Shear Wall 7 --7---T--'lta7tq M44 i,/
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath z/tz/ta
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL 7/14lts /a--
<br />Certificate of Occupancy
<br />Notes Remarks, Etc.
<br />COMMENTS
<br />L.N!d ! Arldt$._
<br />Erection Pads
<br />44:t
<br />Flood Zone Certif.
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