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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMEN IS OWNEA BUII,!'ER DELCAR{TION I hscby ailtrm undq p@lty olpdjury lh, I on .r.ibfl aio'n lh. ConrEclo* Lic.nse l,a$ for lhc aollowit8 rNn (SE 70ll 5 au.in6s and Poa6sio. cod.)r A.y Cily or Coutriy which requirs a rEhir !d .oNrocr, alr6. improvq dflol6l or (!ait dy srflcxtr , pnor lo ns issumce, al$ rcqut6 lhc applicol lor such p.nnn ro nle a sisoed statcmst lhal h€ or shc is licms.d PuBur ro the !,orisions of $. contracloi s Lic.n&d t s (ChaplE 9. Conrndcts tr nh Smrio. 7000 of Division 3 of thc Bsi66s dd 8n',.sions ('od.)or rhol h. or she s crcnfl rhG.ftom and thc basis tor I h. all.!.n .rdnP{ io n Any violdion olsedion 70115 by e! ,p\Qrr",, p*"ir*ur*''rhc dpplcan ru ac,v,lpmak).rno, norrhrn fi1. hundred dolla't5ool a!,so\ndofrheEop.n].orn'y.nploy6\rrh*a!66rheir*nccobpc6arion.silldorhcwo,(edthcdtudrcisml-rnr6i€d or o,t r€d to, elc r Sd.7044, 8616 &tl Pi'ol6sioB Coder The Conricd's l-i.6* Lrw doe not opplv lo u orvnd ol lh. pr.Fiy $ho bdl& o. ibFovd tlsen. exl who dc such wll hnnsclf or l6df or lhroush his or hd o*n.nploy6. pro!i!<l thd such inp.o\tlMts s. tul hrodsl or oEs€d ror slc Il ho$dd. thc buirlin! or improtlmdt i.r sU Nnhin one )E ofcomplciion. the o\xo( auiilg sill havc thc bor&" ol prelins Ih, h. or snc did nor bnild or Lbpbv. th€ pllps1y fo, thc purrn* of t. s ownd oathe pro!.ny, m€lclusivclyconlraclins \vi!h licss.d conta.lors lo co6lrucl thc projel (Se 7044, Ausms d ttoltsion Code: Thc conr,cror's Lic.nse Lav do6 nor apply ro m oLvns olprop.d, $ho builds or improvcs lhd.on. atrd who contmcts lor slch prcjsrs\irh a Conlado(s) Iice.s€d punumr ro lhcconlracroas l-icde s"I - l havc dd *ill baimain r c.dillcarc of Co,sdrl to Sclf-l6ure fo. sorkea' conrpcns.rio., s t ovid€d lor by Selbn lT00 ofrt I ibo. Codc. for lhc psfo,r@.. of rhe {orr aor which rhc pmnn is iso€d -l hrv. ed *ill mainrain rvo*es conrpsalion iNuranc.. s requt.{i by sdrion I700 of rh€ L{bor Cod€. lor rh. Psfonnecc ol lhc $rk aor Nhich lhis lffinil is isu.d My sortds- coDp€Nlion insuoc. .ei.r ad P.licy number e .difrthd inrhctrform.nc€ollhcwork lor rhichlht ps ir is is$lcd.l shall .ot employ anr pe6on in aiy man d so s to b€.om. subj€cl ro lh€ wort6 conp@rion la\rs of Califomia. ed asd that ir I snouu b..o6. srbjcd lo lhc work6'comptualionprorisioftofsdio.lT00ofrh.Labor(rrdelstsll.fonh*nhcomply*hhrhosPtolisio6 W RNIN(;: Failur. to sarc worksj composalion covgagc rilil fincs up to one hundrcd lhousand dollm ($1m.000). in addir rft cosl ol comp€marion, )d,rrc, !-L!!Nt\ll1)! Fnahyotls]urylhrl I dn li.ssrd undcr p(,risnnr of( haplLr o (c.Nncn.i'u \riih .f rhe Blsines and Prcfsions Codc. ald my licme is in iull rorcc dd.rLr' License Clas:-Lic€Nc Numbs: .cl)![rB!cra!l.[NDlrc-ac.E!c] I lE.by arr lndd poahtofpsjurythat lh6c is a consltuclion lendiiE alMcy tor rne pdtomanc€ ol lhc $!rk for which rhis pdinit ie isnEd (Sa 1097. Civ C.). ATIIICANLDECI.AEAIIO! I h6eby a,lDn uidd !oal', of Fjury one ol the tollos ing dNldal ions ttmolirion Ptrmic-tubelos Norifi.alion F.ddal R€gularions ( litl€.10, Pa16) -R€qtrt.d Lelrq otNorFcario. _ UDi{L:Jr,t ,hr rh. r.d*r rcsu ldrioG r.sd.!n! abeh \ rnc"r tu ' nor Jpplicabl' ro rhl' prcrd L4l cdity rhat I har. rad rhs applrcah.n dd nal. rhe rhe ahv. idaomarion iscorc.l.I asre ro conply *hh .ll Cily ann Coutly ordi.,ncs and starc liws r.hl in3 to building al{lc,nmrio..d lropdy for isprlioo kippricinr or ^smr sisn.rur€ Nl.n irenrn,ttprn,r):^*t Cnyand ( ountyro dts upon thc Set Backs UFER Ground SLAB Floor Subf loorfu enVl nsulation Roof Sheathing Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif /) FINAL la/at//A 1F gn^b) Certificate of Occupancy \JV V Notes, Remarks, Etc. Forms/Steel/Holdowns Erection Pads undo pdulryolpcjuryone olrhe nntN in8 d€claEtions L.nder's Ad&e: -44" I I