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SITE.WORK DATE ID/SIG.COMMENTS ()llNliR Irt tLl)tR t)t.il,("\R,\1 l()N
<br />I hcrciy rr'finn ! s prMlryol p.rjury rhrr ! oncrcnDl Imrn rhc Gdrock6 Liccnsc liw nr lhc lolhwins rer$i (scc?(r.ll5
<br />Uusincss {kl Profcssio C&c): Any Ciry or Coutrry {hich r.qotc\ , trhir t, ..n{tu.r. .h.r, i'npovc, d.nmlNh ot rcFrir rtry
<br />dddurc- !!hr ro irs hsurrcc. aho rcquircs rhc lPflic!trt lor .h Fihn ro filci sisncd srarcmnt rh hco. lhc n liccn\cd lur\u.nr
<br />tr rh. Frvision\ of rhc Conrra.tr'\ t,iccni.d l-rw (Chuptcr 9- Coo,mcrci'r! wirh Sc.ln 7flIl oi Divnbn I of lhc Busifus and
<br />Pmlts idF Codc) or rh r h..i\hc is.x.npr rhdretrnmuJ rie hnsis lnrrhc rlfug.d crcmlri{rr A.y vn,hrtun of S.crim ?011 5 hynnt
<br />rnpliclol l'or a0cnn[ suhj(k rhc 0ptlicatrrror.ivilp.nrlryornornrr.rhrtrlivchxndnddolla\(S5m).
<br />-1.
<br />.\ o*mr oi rhc pn,pcnr, or Dy cmpb)ccs wirh qr8c\ as rJrn \'b .onrNnqrion. will d. rh. trolk d th. nndrc 1n.r
<br />i' cirL{ or oncrcd lbr sllc ( Sa.7(}14. Eusinc$ lnd ltolts(,s Codc 'l hc Co0tacrois t,iccosc tlw docs nor aprly h & o*ncr or
<br />rlr pmFny wlm builds or in{,orcs t}rNn. fit *ho d(f,\ \uch $ork hnn\clfor hc^clror rhhuSh hil or hcr owtr cnlroyccs.
<br />Dhvidcd rlni such nn!rclcmnrs m nor i' .ndcrl o. ofliNn n nic. lt how.vcr rl,c hui ilrA .t nlll'mvcmnr i\ sll sirhin , m )!Jr
<br />of conrlcri'n. rhc O! ncr Buitler *ill hat rrE trrbn of roli.3 rhd hc or $. d il nd hui0 or iqrovc rhe pFFny for th. purrne oi
<br />l.r\owncrollhcpnpc,ly-amcxclurirclycontadin8wirhli..nscd.onrrcr.rsroon{rudth.troj.cr(Sc.7(}rl.B!\inca\
<br />hntsrbn Codcr ThcCotrro.ror'r Licc.sc ti! doc\ nor rmlf ro anowicrofrrup. yuho buildsor i'npn)rcr rhcrc.n.
<br />who..ntr(lnr\uchpnUc.rs*irhrO)nnad('(s)licctr\cdtu$(0rkilhcG,nrrtur{nsLiccn\cljw)
<br />-l
<br />rnexcmpl undcrScclbn-. a & P.C. Lrlhis relson
<br />Owncr
<br />IO.BKIBS].COITTENSAIIANtt[rt .Btrua!
<br />I hcrchy arltnr undcr ncMlry ot,rcr,ry orc olllrc hllowins dcclnrdiotrr
<br />-l
<br />hdlc dBillnrnrliirrCcnirlrlc.fCotr*nrbScllli\urctur*orh.r\-..nrFnrrridr.d\pn)rdcdlorbySc.rionlT(xrolrlr
<br />L hor codr. for rhr pcrformanccofrhc sork lor shichrh.!.nnir i\ i\rucJ
<br />_lhuvcrndwilln nrl *orkc^ .onr0cnsrrion iNunmc. ,\ rcquncdbysLrriotr:17rx)olrhcLllxr(:{nlc.I{nrh.I[rrornhnctor
<br />ihc {.ri tur Nhicn rnh !.rmir is nsucd My * orkcr' conDn{rion iNulr.ccrrtricr arylrni.ynun6er e:
<br />ErInc\
<br />-l
<br />ccniii rhat ir rhc n rfornDRr ofrhc worl for which rhk p.nnir N isud. I shlll nol cauloy {n} |Eron in any matrncr
<br />$ dro tEconE shjcd ro rhc $orlcF c.hpcnsarion laws oiCrlilornia. lnd leEc rhar ial should h..otu slhjed b rho
<br />srrkcr( comrEnsarion lrorision\ oiSccrion]T0OoIrhc t,0hr Codc.l sull.lonh*nh comply wnn rho{ pnvtn,ns
<br />1VARNING Failurc ro *rurc aorkcr' conrpcn\nriotr ..rrngc is unlrwtul, .nd shall rubrccr .n cnrJrloyrr lo rinri.al petulrtl $d
<br />civil fincs ut ro om hundBd lhouwd dollas (Sl(D.mo). in addilion ro thc cost or comrcns.lion. dnnDscs !s provid.d ftn rhc
<br />S$lion:1076oilhc Lolxr Crxlc. irtcrcslond lltorrcy s iccs
<br />D.ler Applienl:
<br />I I(]FNSFI) (I}NTRA CToR
<br />OEI;IAf,AIIQ!
<br />I hcftby r,fiirn undcr pcnalry ol Frjury rhd I an licenEn lndcr pmvhion ol Chrrrd 9 l.o ntunc ing wirh sccrk n xD0l of Divisiotr l
<br />.f rh. tlusinc$ ond Profcsions Code, md myliccns h in Inll lore ud cic.r
<br />A.EELICANLIES.AAAIA!
<br />I llnbyllt]nnundcr pctrrhyoipcrjuryonc of ihc lnllowinedc.larrrnn\:
<br />Dctr{,lin'n Pcrfrirs Ashcno\ Norificarn'n Fidcrrl Rcgulrrio!\ (Tirlc 40. Pda,
<br />R.qut.d l..rrcr olNoti,icrrin,
<br />-l
<br />ccniryrhll lhe radcolrcSuhlionr rcEordnr8 0slt{dsrcnDlrlarc mrnrplicant ro lhisrmjccr
<br />lc.nLlr"rhrrIlHvcrcxdrhi\rltli(nnn,:u nnrc rhrr rh.rh)r inntrDrri,n, N$rc.r Irlrccr(,.orflyrirhrllCiryrtrlCourly
<br />r(,tn I,u,r,^..
<br />,rr,priranr nr \xH, sixnb,utu tA \-ra.-\
<br />I,rmriree num(pnd):r* l-rt t N e.)
<br />.,", .0R.- \3 -tQ
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />l\4aso n ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />lqputy Final Report
<br />Engineer Final Report
<br />FINAL
<br />Cerlif icate of Occu pancy
<br />BUILDING- INSPECTOR RECORD
<br />Forms/Steel/Holdowns
<br />Flood Zone Cefiif .
<br />Notes, Remarks, Etc.
<br />IONSIAUCII()NIENDINCrIGINI1
<br />l\sucd lsc. 1097. Civ C.)
<br />Ixndc.s Nanr:
<br />-
<br />lr{c' \ AJ'I,..
<br />I
<br />I
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