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SITE.WORK ID/SIG COMMENTS OWNER BUILDDR DN!,CARATION
<br />I hcrcby aintrr und.r pcndlry.r pcijury rhd l am dxcnu liom rh. CotrM.rrs l,i.cnsc tiw lir rhc lbllosirE rcN)n (Scc?Oll5
<br />ausincss d.d Profcssion Codc) Any City or Coutrry which rcqutcs r lcnnit lo con\rruct. lllcr. imrrovD, icmlish nr rrin Jn,
<br />nrucrurc, prhlro ils nsulnce. aho requts rhc atplicanl for such pern r ro lilc a siancd srdemd thrr lE.r shc is licctr*d puru0
<br />lo rhc provisiotrs ollhc Contrclols Lienscd kw (Ch.rrer 9. Comnrnci.E sirh Scclii,n 7000.l Divkn,n:l Dr rh. au*inc$,nd
<br />Ptufcsn,n\ Cod.) or rhd h..rsh. h.xcmrr rhcrcrR,fl rd rhc ltrNis f.rrh.rllcgcdcxctrrtli,rn. Anyvnnfllion.aScclion?(J:ll5nyony
<br />l'lpli.nnrtorapcnnitsuhjNlsrhc,pplicanttoacivilpcnalltolnotmorcrh0nfilchundrcddollm(55u))
<br />l.aro*ncrofrhcpn,pcrlr-ormycn,tlorteswnhsrgcsasrhctw'lcco'nFnsrrnnr,willdodusurtand$csmrurcisnor
<br />i cnLd .roffcr.d r srlc (S(T(x4. Ausincssnnd Pofc*i(,n\Codcr ThcConlhcktr s Liccnsc Ltrw docs .or lpplr i, rn ownrr ol
<br />rhcpmFny wtu huilds or imrmvcs rhcrlr)n. md sho dms \uch sork hinN.ll or hcr\clf or rhrulah lris or hcr ow c.'ployccs.
<br />D.ovidcdrh such rmrrotmnr m mt intcndcd oroll!rcd for srh li howcEr rhr hilding or in{'ormnr i\sold *irhinond Jtar
<br />of (nirlcrtnr rtr Osncr Buiuer willhalr rh. burddnof!rcvin! rhrr h.orsh. did k hoild or iiryrovc rhc pm|cnr lor rhe purF){ol
<br />-1.$ownerollhctbpcny.amcxclusivclyco.liaLlingwirhliccnsLlconlra.ronroconsrru.lhcrujkr(S..7014,3u\ir'csx l IbfssixrCodc'fhcContr.txrLi..n\chwdocsiorapplyr.ni.wncr.flropc ywho huilds orimprovcs rhcrcon.
<br />and who conln.r for such pmiccrs rirh. Conlmdons) liccn(d purua ro thc Conkocrois l-i.cn{ ljw)
<br />I mcx.6pi undc. Serion . B. & P.C. ro.lhk rca$n
<br />Dat. O*ncr
<br />IYaErllBLCAUfli8S/r:Il(2!
<br />DECIANAIIOX
<br />I luch,rlln undcr If,ulirofpcrJUry oi. ofrhc f{,11,)$i',A dc.larain,n\
<br />-lhave
<br />d will nuinllin a Ccnificale of Coleor ro Scl{ lnsurc ftr sorkoi cdmp.nsar i. . as prcvid.d fo. ny Sd ion l7m oI rhc
<br />L$or Codc, rorIhc psforrorcc oflhc wort for shich lhc ptrir nkued.
<br />I hr$ rtut *illnuinrrin *o cre comp.n\rri{,n in\uraicc. r\ rcqdtcd bl S(rnr lTtD.trl!- IjtDr Codc, itrrhc pcrli,nnrNc of
<br />rh. work i{tr shi.h rhi\ p.rnrir is hsLd My sorkdN .!nrp.n\rrn,n in:um c.inicr.rxl t'ol[y nunrti.r nic:
<br />lccniryrhrr inrhc F,rronmrccofrhc wort for qhah rhk plirnn n Gsucd.l shallnor cnDlor!!y pcN)n inanymrnncr
<br />$ r k, bccorE subjccr ro ihc wo,lc mmFnsari,n lass of Cllifornia, md ssft. rh,r it l sh)uld lE om suhFrl ro l6c
<br />No*er conri.nstion prevGions ofSccrion]r00ofthc Lltnr Corlc.l stull. Lnhwnh..mfly *nh
<br />'hoc
<br />pnvhionr
<br />WARNIN(;: Failnrc ro $.ur workctr coq).niarion ..vcdgc is uihwrul rnd shlll {bJcd !r cnllLylr ro oiminll Fnrlri\ niJ
<br />.ivil l,ncs xp kr onc hundrcd rhauend dolltrs ($lm.{XX
<br />sccrn r :1076 of rh. hbr c'odc. inr.rc{ and axonEy s f&s
<br />i,rn. drtrEgc\ r\ pnridrd f(tr thc
<br />,1 ({n
<br />q+Lw"-,.*".,4 =_-
<br />I lrrcby rlftrn u.dcr Fnalry of pcrjury rhlt lh.r is i connruci.tr hndins a-qcrcy lor rnc pcdortu.c. orrhc $.rk lor which rhn P.rnrit is
<br />hru.d (Scc.1097. Civ. C ).
<br />APSLICANLD&SAAAIION
<br />I lrEby ofmn u ndci lcnany of,rcrjury onc ofrhc lollowin8 dcclarali.rs:
<br />D.molirio. Pcnnirs^sbcaos Notiti.arion FcdctuI Rcgullrions (Tirlc 40. PM6)
<br />Rcquirol t xcr of Nodf cali.n
<br />-l
<br />enilrth0t lhc ictlcralrc8ulalions rcBardnrs aslEsl,x rctr&ral rrc nor rpllic$lc tu rhis lm+cr
<br />;,,;_;;;;;_,;;";''L"tritt,4 &,ula ^,", -f 1lf rr
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Su bf loor/Vent/lnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framing ia-2'/ B 4zz-
<br />lnsulation/Energy
<br />Drywall
<br />Extlfni2ath 17 -?-t8 ,---<da >?A
<br />Brown Coat
<br />[t/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />-''2 L_-\)
<br />FINAL //-///'/ z).4C tS,ttZ,z-Y'{ Z//
<br />Certilicate of Occupancy
<br />Notes, Remarks, Etc.
<br />BUILDING- INSPECTOR RECORD
<br />DATE
<br />I hcaby,rauD u.dft penalry oi pcrjury lh.t I an liccn*d rndu pmvnion oIChryrs 9{o'nmacina wirh Sdri,n 7fiD) ofDivhion.l
<br />or rhc Ahinc$ and Protcsri.nr C.dc- ,J'd 6y liccn* is in fnll ion dl dlrc.r
<br />Lrn'lo . Addrc*
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