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SITE-WORK DATE ID/SIG.COMMENTS O\I NER BUIt,DER DEL('ARA'IION <br />I hs.by amm und6 r,oahy of rdilry rhd I m .r.mfl lrorn rlE Conta.rou Li..n* t:* aot the followin8 taen (ss 70.l l 5 <br />Ausitr6s ud ProfRsi. Cod.): Any cn, or Counry vhich r.qut6 a p.nnir ro .onsrruci, alt6, improve dcmolirh or rcpai My. <br />sle.lue. rioi b irs issumcc. aho Eluir6 lhe applicant for such rEni to nk a sjsncd sl.lmol lnal h. or sn. is licdscd puuua <br />ro rhc provisions of rh€ Conl..crois Lic.trs.d tiN (Chapid 9. Conrmencins sirh s(tioh 7000 oI Division I of lh. Busin.s md <br />ProfBios Codc) or rhat h. or sh. is cxenpl rha€fiom aod rhc bes fot rh€ .ll.sed cxflplrn AnyriolarionofS<ion?0315 by any <br />npplicanr ror aF.mn subjes th. applic,nrloacivilrnahyofnolmorcrhdfiv.[trndr.ddoll{s($500) <br />l. s owd olrhe rroD.ny. or m, .mplorc $ilh $ d86 s thcn $k comp@lbt. *il do th. worl ard lh€ nrucre b nor <br />inruded or oit-€d for el. (Sd 7(144, Bosins and Protsio6 Cod.: Thc cohlrtclois Lic.N l-€{ do6 nol arply ro M o$n.r ol <br />rh. pop.ny $ho buildr or inprov6lh6@n, ud who do6 such m* hins.llor hBsclfor thmush his or hd owh employ.6. <br />prolidci lhat such inPIo@rs e mr idoded or.lIerql for sE I li h.s'6 5. rh. hildinA o! imp.ovoE issldwithinon.d <br />ofco'npkion. rh€ O* nq Buikrd M[ h,!. th. brda or!.ovins that h€ or shc drd mt h]in or imptu\ e thc pDpdy &i rhe prpoe of <br />-1. <br />s omd oarh. propdy, o. .xcl6iv.ly contacli.s wir[ lic@.d .ontocto6 lo constuct rh. lroj..i (Sa ?0a4. B6iod <br />rnd Aoltssiofl Cod.: Thcconador's Licms. Las do6 not apply to u ow.r of ropdy sho boilds or inpror6 rhdo.. <br />and who @it6ds iorsuch prcj.ds wnh a Conldclo(s) li.cBd pursu&r toth. Co.lEcrofs t,ic@. Law). <br />I m cx.r.pl udd s(rion-, B. & P.C for rhG rN. <br />lvalEEB$ll)lltEllarla.N <br />DECLARA'NON <br />I hdcby amnn undd po.hyolpEjury onc ollh€ roll$vnrs deldarioG: <br />-l <br />hare & *ill mairrah a Ccn ificaie ol Coodl ro Self-l6ur. foi $orkst anrp ario.,sptuvid.nlorbySetionl?00otrh. <br />l ibor Codq ror rhc pdfomme oi th. wolt tor whi.h lhc psnit a s!.d <br />-lhaleandsillmainlainworl.Bco'.p.nsationiGurancc.stcqutdbySsltunlT00ofthcLtborCodc,forlhcpolobnturcolfor $htrh rh6 D€m F sucd Myl^"rlss*a*p Iunol conpdsdion i6uru.c cMis ad !oli., nrmbd a e: <br />4Lt (3(Y (' <br />Ycoriryrur in rtrc erromanc. orrhe wo,k ror which rhis pd,nir s <br />so 6 ro beomc subjEr ro rhc s 6' coDpe6arion la*s oacalilomia, <br />sork6 comp.Nlion pmvnaoB oas$rion 1?00 o l lhc hbo! Co!e. I <br />issucd,I shlll nol edployanyp.rsofl itrayidnd <br />dd dsftlhar ifl sh.uld b..on subjdl torhc <br />slull, foflnwnn omdy wilh lboF povisioN <br />\IARNINC: Failure r. suc sork6' comperstbn co\€mse is unlawtul. 4nd shall sn d mplold to aimiral p6ali6 dnd <br />civil fin6 up ro o.. hundrcd rhoMd dollm ($100.000). in ion. dana8.s 6 providcrl lor lhe <br />S(rion 11076 Lltrhe t .r <br />,,"," 1rfl,.tf1 <br />code. nn6es1 d anomey'sI <br />I oE(!tEulal <br />I heicby anifln undd ,oalry oi psjury lhal I an li.6sd undd rovision o I ins NilhSdion 7000)oaDivisiotr I <br />ol lhe Bcins ed ProfNions aod., ond my lic6s is in lull ro(e dd clld. <br />P,lnnqbu2 <br />,rr," ll IY .",,."",.., A6C <br />collrallcllaN.L[rDMicllcl <br />I h*by aIlmn undd psElry o r l9jury rhal lhd. is a consrucl ion kndins aso.y for th. Ftom&cc of lhc s'or[ aor {hicfi ihis psmil is <br />isstr.d (Scc 109?, Civ C.). <br />A.E&IANLDICI"ASAIIOX <br />! rE$yatrnnunda p.n.lty of prjury on oilh. follo\ins d..lr.tions: <br />D.,nolirion Ps,nns-Asbelos Norificarion Feloal Rcsllarions (lillc 40. Pan6) <br />R.ituncd Ldta ol Nolifi.slioo <br />I cdifynd rhe iedsalresuhlbns rlxt lins,slBros r.mo\.1.r€ nol apphcabl. kJ rh6 proic.l <br />14 cdiry rhar I haw .ad rhi. applicarion drd $are rhar rhe abov. in dtlr is.ond l lsra lo corply \ h all City tnd County <br />.'(l a(Nrnd Sr.rc La$srclatiD! I rize rcpreml.lnd olrhis cirt a l ( otrntyi <br />itro!€ metrl ionqj pro pcn y ror ,,I.- <br />Applicnnl or B6l SiBn{lurr <br />LUAa- <br />,"" l(t1 <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />SLAB Floor <br />Subf loor/VenUlnsulation <br />Roof Sheathinq <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Ivlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL tl Ln\tg b- q,')etleli /"ttV,9 <br />Certificate of Occupancy <br />Notes, Remarks, Etc <br />BUILDING. INSPECTOR RECORD <br />UFER Ground <br />rt <br />r-------T------ <br />l <br />I