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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUI LDER DEt,('ARATION I hocby rflirm utuld FDlty oirojury rhar I m cx.dfl nDm rhc Conha.roE Licm li\r lor rh. lollorinr r.etr (Ss 701r.5 alsin6s .nd Prol6sion Cod.)r Ant City or Coudy $hich r.qun6 o p6mil lo conslnrct. alt6. improve, dsnolish or tpair dy srtudrq rior lo irs isuuc.. sl$ r.quiB rhâ‚¬ qlpli.d for su.h !.mil ro 6lc a sisned statmml lhal hâ‚¬ or shc 6 li.ors.d poNafl ro rhc provisions ofthc Conrdcrois t,i.c.*d L.rv ((haplr 9. Co'n,ncn ing $nh s.dion 7000 of Divisioo I ollhc Rusins &d Prefsi.ns (ode)orrnar h.orsnc b.r.nDr tho.lrornandrh.hsk aorlh.allcS.d cro.plion AnyvioldionofsdhnT0.ll5byey applica for a pmil subjdl3 th. applic.nl lo rcivilp.nrhyofnor morelhe liv. hundr.d doll.6 ($500]. I. 6 owncrollh.I,oFry. or my dnployB silh salsa lhcir sl. compâ‚¬Mlion. rvilldo Ihc trork and rhe ntodu. G ml intd(H o, orr.d for slc(56.7044. Ausin6 rnd holsioN Codc: Th. Coitadr\ Li.@ Lr$ do6 nor.ppltro.tr 0\16 oa E pNp.dy who h & or imprcvB $60., aftl who do6 such *o,{ hins.llor hdsclf orlhrr]u'8h his or her o\yn cmployeB. prolid.d thd such inpdcn nt e nor i ad.d .r ollddi tr)r sL ll howdd. rhe hriL.liru or nnprovdnâ‚¬rn is $kl *irhi'r otrâ‚¬ yw ofcomplelioo, thc OM6 Srildd will ha\r tlE hrr&n of poi.s lhd hc or sh. dd nol build 6r iqrcrc rh. prrFry for fi. purpoF ol El. * o" n.. o r rr,. p-p<y. - Bclstr ely (nnra(r! s'ilh liccs.d co radon tu .oBrtu( rh. prujd (s(. 70.1.1. Busins and PJlcssi.h Cod.r Th. conta.rois Lic.ns. Law dos nor apply'o an oNn6 oapropâ‚¬ny (ho buil& o. nnprove rhaon. a.d *ho co !a.ts lor such projc$ $ilh a Co r.cl.(s) liccnscd pusodr totn. (bnlrnclois Licen* Lav) _l@cicmpru n S(l'o._ ,B &PC I^r rhi{ r.asaa ,- ! ,.," . t[lr-UlaolL -".,,). "Xryo Z ddl!oatrEa5i!r!t[!.la.Ua! |-DE(IAIAIII'! I I hdcby amrm ufldq p.nllly ol lqjury onâ‚¬ oflhc followins d<ldalio6: I halc d Nillmainrain a c6lific0t.otConscnt lo Self-lnsurc tor Norksi conDcnsalioi, as poided Lrbtsdior 1700of lh. Lrbor Co!c, fo. rh. p6fom&cc olthc worl lor *hich rhc pamir i! iisucd I h.vc af,d *ill mainl.in *ork6 compâ‚¬ns.t ion isu,onc.. s .eqtrned by Sd tuo 1700 ol rhâ‚¬ lrhor Cod.. tor the lB nrmec. of Itc work lor whi.h lhie p6mil is isucd My workdi onrp$srion insuBncc cri6 dd poli.y numbd &.: E\ cenr$ rnar in ltrc psromwcc olthc \orl lor trhi(h $is psnril is issued, I shallnor dnpl.y a.r t6on in otry mntrre! s 6to beod. subjsr lo rhc $0116 .omposarion la$ ofC6lifomia..nd +E thit ifI snouH bccor.. subjal lo lh. (0r[6.o,nprsarionpmvtionsofsdion:J700ofih.Lah.rcod.,I3haU.fonhwithcomplywill,lh.spnvnions. ltAliNlNC F ilur. to Kuc "orkm ompds.lion covelas. is unla*ful. ed shdll subjd d dplo}cr ro oihiml tEali6 md civil fin6 up to on. hnndrcd lhouend dolltrs ($100.000). in addilion lo thâ‚¬ cosl ofcofrpâ‚¬.strion, danaBs as Oolided aor lh. s(rion r0ro ofrhe L.bor Codc. inrsqi ,,,,", , lo lzil 2ol( DECI,AAAII!]ts I n@by anim undq poally of pqjury lhar I m licdsd u.d.r a,ovision olChaprd I (co,nmncing snh Se.liotr 70Ct)olDirisior l or lh. Bnsin6s ed ProadioN Code, md my lic.e n in tull 4o... dd .rd. qaNlrauc.ullrL[rDlNclcENcr I h.Eby amm und6 pcrahy of psrury lhal lh6. b a cotrrruclioo Lndins asdcy for rh. poaomdc. 6a$. \ ort for \rhich lhis pq.n b isstr.d (Sd. 109?. Civ. C.). atauc .NfD[qdaalt()N Ihaebyamnn undcr pcnally ofpqjuryonc olthc lollosins decl.ralions: D.molnio. P.mtu Asb<sros Norifi.arion F.ddal R.guhbns (lnk40, Fan6) Requircd L.ucr olNolinc.liotr I cdin rhd rhc f.ddalraLlarioN Rddin( 6besro, rerno\il .ro!appl'c.hlcror\irrajd..1{ tsI (d'fy !ha' I h!!c rsd rhB EDI'c,r'.n dJ !a'c'h,rrh. ahov. inlonn.rnrn i.oftdt IaSrd(ocomtlywirhsllCilya.d(ouly orlinaoc6 ed Sralc rrws Elatinr ro blildins co.srtodioa &d h6.by auhorn.r.pr6nl.liva ofrnis ( ily.nd Counl, to sl6 upon th.. lo)-L6lLQil Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subf loorfuenUlnsulation Roof Sheathing Shear Wall Framing ln s u lation/Energ y D rywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif l FINAL 8/74ry /M4 ) Certificate of Occu nc L Notes Remarks - Set Backs , Etc. aboLc nrelr(.n.d pmndy f.r iNedon p5:)F c -l t Appricnnr orAEm, siqnr,ure >1 J'//{\- C^ dodlf\ ronrrenrnerprino, !( [.y4f,]q$f ' -------T------ T------