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SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DtrI,CARATTON
<br />I hcrch, affirm u ndc! F ally oi pcrjury ilEI I om cxempr ,on rlt ConadoN l-iccnr l iR rot rhc r.uDsiIE rcaY'n (Scc 70-1 1 5
<br />Boriness ,nd Piofcsio. Codc) An! Ciiy or Counry which rcqutc! o ,cnnil ro Nnrrtu.r. alrcr. nnprolc. &mrltl' or rPair rnt
<br />no.Nrc. nrnnro irs hsuarcd. also rcqxircs rhc q,plic.nt (n suchI4rmilb fiLangncd sarcnf,trl lhllncorsh.hli.cn\cd,ursrflr
<br />ro ihc fm!(ions of rnc Conlracloir Liccn*d Lrw lchlprcr 9, Con ncncing wirh S.criotr TU|O of Divhbn :l ot rh. Btr(in.N rnd
<br />Pmfcssions Codc)orrnd hcorsh. iscxcmpl rhcrcrioma rhctN\i\ f{, rh. rllcAcd cxcnrflion nyriohrn,norscdi,nr7n315b,an}
<br />op,,licunr !u a p.rmir suhlc.h rhc nprlicanr Io acivilpcnalrrofn.rnxrcrhM fivc hundred dol16 ($t00)
<br />ILI!. u. "**, "t '
<br />t'. p"r.,y. or m, r ,rlnyccc * (h wascs alhcir slc co'npcnsdrion. wiu do rlE q ort and
<br />'hc
<br />{dm I nor
<br />inrcdc{ oronircd ft, ek 1se.7(l14. lrurims\ and Pofc*ion\ Culc: Thc Cbnrnctor's Liccnt liw docs nor aplly to 0n owrcrol
<br />rhc pmFny who trilil\ or impRlcs rhmn. arxi wk) &$ smh e* himscllor hc^clf.r rhsuAh his or hct o*n€mpk,yc.t.
<br />tovid.d rhd u.h nnFovcmnh e n inrcnd.{l oficrcd fir $lc li lx}"trtr. rlE Sdibir! or nqnrt,nm is $kl wirhin om FU
<br />olqnnplcrior rlrOwtur Buihcr will hrlr rhc hur'lcfl oilrrovins rhlr lror\h. did fr lDild or irDrovc rhc f,m!.ny for th. Puqns ol
<br />I. i\ owr$ of lhc rrcncny. am ci.ltsivc ly conta.rnrF uirh li.cr$d coMuulr$ h Lur{dcr rh. P' tic_t ( Scc '7o'lJ. BusD.$
<br />(n hDEsin Codc Thc Cont,.k, s Liccnsc Ld*' docs rFl 0lrfl! n, xn .w i$ or f(J,'c y who huilds or imPov$ rhctcon
<br />d qho.orB.rsr(,suchtmj.rr\*irhrCotrrRcbnsrli.cr$dtursnnllolhcGnnrrctn'\l-i..nscbs)
<br />I ancxcn$ und.r $dion-, B &
<br />('' r^*. X .,
<br />I2ICLAAAIION
<br />I hcrchy allirmundcr pcnalry or pdjry oN ulrhc lollotrir8 dcchrirtnN:
<br />-l
<br />hrvcuxlwill nEinrain a C.nifc,r c o r Conlcnr ro sclf.lnsurcltr sodsr comp.nsdnnl. as Pmvidcd for bysdriotr:l7lD ofrh.
<br />ljb.r Cotlc, Lr rhc pcrformncc ol lhc *o.* for whah I hc ,.mit is issucd
<br />IhrtcrtrdBillrnnirrainworl.rs.onlrn\.rionrnsumrcc.os rcquircd hy s*rion 17(() .l rhc trMr Cod€ f.r rhc Pcrfornm.c ol
<br />rhc work l'or *hth rhi\pedir ir iss.J. Myw.rkds .ompctrcolion ir\ur cc.nrid tuxl!.licy nunrhcr @:
<br />0Sr *,rlryrm * rr'" p,r",mrnccofthc sort ior *hichrhi\ p.i, n i\ n{ucd,I slralr Fr ctrDlo, 3nt ,.^.tr nr otrynranncr
<br />$ .s ro b.ronE suhicr ro rhc $orkss conp.mnrion lasi orcalirornia. md asr.c rhar irI should ttom subjecio rht
<br />woikcF'compcnsationpnlnions.fS.ctionlTO0ollh.bh.tGxlc-tshnll,r.nhwirhsrPly*ilhrh)sPolhions.
<br />\YARNINC ruibrc ro $cu. qr.kcs con,Fnsarion.ovcruac n utrldwlul. rd shall srhj*r 3n cnDk)rtr ro diDind nc'ulric\ dnd
<br />.ivil fin.s ur ro onc hundEd thousdnd dollatr ($1fi).s)0). irr tufuiln'n n, rh...sr .r conlt'ctrsrtion- dlnug€s rs [ovid.d nn th.
<br />Sc.rior 1016ol lhc lnsirC{x|.. i'lc.c$ rtr ront! \ flt\
<br />7- >6 _/g
<br />DECLAMIIOtr
<br />Ihcrbyaffirnud$NnrliyolpcrjurylndIanrlic.ndu.d.r!n^Ni.nolChaPrcr9(coarnttunrSqirhSccrhn7$o).fDivi\n.l
<br />oI rhc llu\irossn'd PmrcssionsCodc. onl ryliceNe n in tullfuo rnd dffd
<br />C0NSTRIJCTION I FNDIN(: A(:FN(:Y
<br />I herchy lilirm unarr Fnairyorr.qurylhit lhcrc is a.oNrrudior hndnl8 t8.my forlhe N,lorroNc orrh. work td which lhn pcrmir is
<br />isucd(s( 109'7. ci! c )
<br />A.EEII(:AILDIiCLAAAII}N
<br />I ho!'try alfin undcr Fmh, of r.r.,ury om ofrhc iollo*in3 dc.latarion\
<br />ocfrnirn'n Pcflnih Ashcdos N.rifi.ari.n Fcdcidl RcSularions (rilbJ0. P!n6)
<br />-Rcquircd
<br />Lxrr.r of N.tifi carion
<br />I ccnilynr thc fcderal rcgulariorr Ng,rdnrg 0lb.{os rcnnval rr c trol omlic*lcio rhistrcjccl
<br />@(,enily riDr I hlh Ead rhir nmli. ion orn s.rc rhol rhe obovc int{nBriotr i\ c.md I lsr ro comply wirh nll cil y rtrd Counlv
<br />idinanccs qnd Srole lj*s mlnring ro buildi.g cotrrrucrion. od hercl,y aulhoriz. r.trc*ntarivcs olthi Ciry and Counlylo cnlcr uPon llr
<br />rhov. i*trri,nrd Frpcny lor inlpcdn'n N'Tx
<br />Applic.nt or AEenl Signnlure:)<
<br />oftl.,rn,irerNn(,rritr,,: Y- A/do< f" t4 /b
<br />D^,"(7_2.6-1k
<br />Set Backs
<br />Forms/Steeli Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsu lation/Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL g///(f7)4r)
<br />Certif icate of Occupancy
<br />Notes, Remarks, Etc
<br />BUILDING. INSPECTOR RECORD
<br />Pool Fence
<br />Flood Zone Certif .
<br />I.n,l.,.NJr_
<br />tt
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