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SITE.WORK DATE ID/SIG.COMMENTS OWNAR BTIILDIiR DIILCATIATION
<br />I hcrcby rffiirn uDdcr pcNlly,,fFrjtrry Ihir I t crcnrB lm rhc Cont ttr\'Li.ctr* kw lor thc nnlosinS rcnetr (Scc'7(rll5
<br />Busiic* r,il P(ntsi Cidc)r Aiy Cny or County which rcquirc\ r pdi b.!tr{rucr. r'ltcr. nnptuvc. dcnxnish or rcnxt anv
<br />!flcrurc. piub n\ issuai..,.ho rcqutcs rhc lplliclor lor \nch P.nnir b itcn sisncl \ldrcmnr rh ncot shc n li.cn\cd Duisu,trl
<br />n, rh. pi)rision{ ol th. Conrracroa\ I-i.cn*d bw lChit'rcr 9. Con ncd.i'1! wirh Scction ?(XXl ol Divisn,n 3 ollhc tl$i'rcs dnd
<br />I,roicsion\C.dc)o.rharn or\h- Bcxcm rhcrction,rt rh.br\i\ tur rhc.llcgcdcxcnrPrion Anlvidnri.nnlsecrioiT0:ll5byotrv
<br />lpplicrni n,r r p.rmir subjccts lfu ilrli.rnr t, r.ivilNnrlrtorn.t morcrhrn filc huidaddolhm (5500)
<br />I.*owrcrol'lhcpmpcnr-ornrydnrduyoswirh*necsrsrhcn$hrorltrtr{rn.willdolhcvork drhcslmrurciIrn
<br />inrcrk{ or.ilarcii k)r salc (S€ 7o+r. ausincss lnd Pmfcsions Codc: Th. cDtrtr.toir L-iccnsc l-dw docs nor lPnlv h rn osrcrof
<br />rlrpr)p.ny wlkl hilds ot imttove\ rlIR)n,Ixl qho docs such x)lk hnn\cllor hcr$ll.r rhough hi\ or h$ o*tr cnunryc$
<br />0n,vklcd rhlr such i'npRr.nrnts .nn inrcndlJ orolltnlfor ek ll ho*c$r rh. huiUi're .r in{nxtnrnr is $ld wirhnotrc}tar
<br />or.on1|)lcriofl. rhc Owncr Buildcr *illhrvc rh. burdctr oltmvinS thal hc or \hc did nor build or iDPrnvc th.lm|)(rly for ltr [ {tsof
<br />-l-
<br />r\o*ncr olrlt m,Fny. !mcrclusivclycont(n,! snh li.cn\cd (onrrucr{ns r...irru.l lhc loFcr {Scc 7(xa. Bu\in.$
<br />and I'mfcsbn Codc: Thc Conlrrktr s Liccnsc Lrw docs lor unplyb rn owncr oiFPcrr, *h(, btrilds or i'npm!c\ rh.r.otr.
<br />and who .onrEcrstor\u.h pmjcck wilh r Conlllcxnl\) li.cnscd Pusu.nl rorhcContnctr's Liccns L!B)
<br />I rNc\cnrnr un{l.r Sccr B &PC r(trrhi\rcason
<br />woIxFRs (lorrPENsllloN
<br />DECI.A.BAIAN
<br />I hctuby.llirnrurdcr t^-nulryorFrjury.E olrhc nnbsins J..hruri s
<br />I hrvcrnd rillmrinrri.ncenifi.arc.lcotrs.nr la Scll:ltr\urc litr workcr' c.n,Fn\r n,n * ProvidLrllorhvsccriotr:17(,0.irhc
<br />ljlmr (-odc.l rhcpcrlbnnan.cofrh. w.A for whr.lr rhc ncnnil i\ i\\ucd
<br />I hrvcrnd will muinlain $ork.rJ.otrItnsdti.tr insurlncc. !\ rcquncdhyScclion.lT(XlotrhcLabor(idc-f(trrhcPcrformrccol
<br />h lhi\ rcnn'rj n$cd Mysor[cn utu .c.iricr xlB,licv iumhcruc
<br />C qL'cD
<br />-lc.nilyrturnrrhcp.rfonnrn.collhc{orkturshi.hrhstc
<br />nir h tsutd. I nrall tror .nlrlot itry ncr\n inrnv manner
<br />v,r\t'b..otrrsublR.-.rnrrhcworkcn.drtcfs ionl.ssolCrlifornir.a ttr.rl il I dDuld t tom ub]ltr to rhc
<br />\f r[o\ rr,t)cn\rri], r t,n*i\ or..l Sdrr,r rlrno
<br />\\'AR\l\(;: I Jlur. t) {.tr,. u,rl.'\ ..nDcn\rl
<br />frh Lnh, Co(lc. I shrll, fi)dhwiln conrtny sirh rho*_ !n^hi.ns
<br />is u.l.wful. utrd \hrll srbjLii ,n coploy$ b difrir0l pcrolrics urd
<br />4
<br />o"rF o
<br />up kr .k hutrdrcd rhousand dollas
<br />\lr{ix'""
<br />DEC'.ABAflTN
<br />t'n undcr p(rohyolNrjury th0t l.m liccnsl under pmri\ion ol Cturls 9lLa,nttumnrB wirh
<br />sincssand PmicsionsCixlc. and dryliccnsc n tull lbre a cni{r
<br />C )a-
<br />I!]ISIBIJSIIONII,IDING.EGINCI
<br />I hctub, Jmnnundcr r(trrllyol pcrjury rhd rhcrc is r con{ruclior lcnding aecmy lilr lhc pc,nnnEn c ol rhc wort lirt $hi.h rhis pcrnrit is
<br />i\sucd (Scc :1097.Civ. C )
<br />trndci. :{Jme
<br />-
<br />APPI ICANT NE(:I ARATiON
<br />I hdrby Mim utrdq ncnllry oi Frjurt onc olrhc tolbwnr8 dcclararnnN:
<br />Dr n)lirn,n PcrmirlAstEsros Noiificarn,n Fcdcral RcSul0ri.ns ('lirlc40. PdrO
<br />Rcquircd t ttcrolNorilicdbn
<br />lccdiiyrhrr rhc fc.lcrrlrc8ullr(inr Egx i',9 \h.{.\'cnrvdrrc mr uP]icrblc ri Ihi B,ic.r
<br />Icc'rLl! rlrr Ih r. rctldrln\ r0pL'uri(nrr lnl.rh rho Jlx\. i'rlnnnxriinr Kfto r D(! r d Sitrc Lrs\ r.Lrri
<br />,\Dpli($l 0r,\,!cnlsiantrlu
<br />b huLUnrBcorslruclio.. rtrl hc.cht rtrhoriTc
<br />t corel. I as,c io..mply qil
<br />rclrcscnroriv$ of rhiq Cily ond
<br />rx* (J
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFEFI Ground
<br />SLAB Floor
<br />Sublioor/Vent/l nsuLation.A
<br />K-t7-{r Pr.Vdfi vd
<br />Shear Wall
<br />Framinq
<br />lnsu lation/Energy
<br />Drywall
<br />Ext./lnl. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Beport
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />I
<br />FINAL *ltdlrx 'lvlfiLr4 z.t )./
<br />Certificate of Occu anc
<br />Notes, Remarks, Etc.
<br />C'n L o-1t
<br />O,t/
<br />BUILDING- INSPECTOR RECORD
<br />Rool Sheathing Pftrt.f
<br />?1 vWc Pt ><1'
<br />trnJcis A,l.lE$.
<br />-
<br />I
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