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SITE-WORK DATE ID/SIG.COMMENTS oWNER BUII,DER DELCARATION
<br />I hcrcn, {fllrm uMcr |xmht oi pcrury rhat I m crcnru rmrn rhc ContracroF Licc.sc Liw for rhc r'olhNin8 rca{,n (s.c 70.11 5
<br />Bu\inc\s rnd Prolt$ion Codc) Any Ciry or Counry *hth r.qutc\ | pcrinir ro .on(rucr. alrs. imrro\t, dc'ft'li\h .r rr'rn diy
<br />iocrur.,,rk,u ir\ is\!a .. alvr r.qrircsrlr applicanr ao sochp.rnrir b nb a si8tud e .md th{ tEor shc i\ llccnsd purulnr
<br />t,rhcpmli\i{nNolrhcConrraci{r'sl,i.ctrsc,lL,N(Cha.r9.Gnnnrki'r,ssirhsc.rion7(x[.rorvis$ntofrhclrusinc$lnd
<br />PRnas$otrsCi)dc) or rhd hcorsh. i\ckc rrrrh.dn)nr,.d rhc hrsh frr rh. rll.Bcdcxcm0iion AnyviohrionoiSccrionT0.ll5byany
<br />rrplicarl for iFcnnii suhjcch rhc amli.anr ro acivil|.n.[yolno' morc rhon l]rc hun{llcd dolh^ (S5fi))
<br />l. n* usncr orrh. pftpcrly. or trrycnlPl,irtc\ *irh qucs ds rhcii nrc.onfctrsdnnr. Brlldo thc $sk ud lhc slturlrc n nor
<br />inrcnn.n oroillrcd rbr elc (Sr.- ?04,r. Busilrc*.nd Prnisions Codcr 1i.(,n rrttr s l-ien\. t:w d..s nor .f,tl! tu itr nsrcr or
<br />rltrlNFny sh. hoilds or irym\rs rh.Kri. xlslx)d.c!su.hw)*hnnscllorhchcllorrhr.u8hhis.rhcroN..mrloy.$.
<br />p(,vidcd rhrr such impro\rmnc n nor inr.ndcd or oitEd for $k ll l kru. rhc hiklin8 or inpn,vc rd is *,kl $i,hir onc rcu
<br />ol.on!,!rinr.rtEo*trcr Buill]s willhrvc lhc bodcn ol [ovnA d hcorrhc i]il trorhui or iq,royc rhd pmFiy fttrrll Nib*.r
<br />l. a\ owrcrolrh. |rrolcny. nrxrlu\iv.lyconrrncrin!sithli.cnscdcontrtr\r,cotr{.rrh.tniNr(Sc.7(11-1.8u!rcs
<br />ind Pnnl\rbi Co'lc 1h.Co rido.s Lrcn!.I-rw docs Dorrfnlyt, rnos.cr olt(it'c r_ Lrhn huil{ls or iDtmvcs rh.rron.
<br />rnn $ho conrricr\ rbrsuchprojccrs*iihr ('oDrrncro(n liccnscd pur\urrrbrhcC.nhcn,\ Liccnsc bw)
<br />lr rcx. rlr rtrJ.r Sc.rlotr .li &PC lirrhi\r.rnrl
<br />l) e ()sn€r
<br />]laBnitsrraNtrN$/rllaN
<br />DEllrIntrIlON
<br />I hcrc6y rlltn undcr lrnally ol!.rtu.yotrc ol rhc lnl[){irg declnuli(r!
<br />lhr\cr'[] N'lliridr rCcnii.irco,(-r {trrt)Sclllisui.tursork.r!'..nr.nsrrnio.ds!.oriJ.di,nhyS..ri.i:17(X)ofrhc
<br />I rtrtr (', .. knrhc pcrformrn.c of rhr$ork lnr ([ich rhc p.rmir i\ n\urd
<br />-lhi\c ond rillmainiain *orter' .onrpcn{rion instratrc. N rcquircd hySccrlon.l?0Oolrhc LabuCodc, forrhc Nrfitrnrn.col
<br />rhc snrk tu,\'hi.h rhis Pc i\ i\{'Rl My*orkc'i.otr,rcDsrri{nr i',{nn.d crricr rnd F,ltrnnnrhcr c
<br />tgoo
<br />IccniSrld,nrhcr.rtornutn.0olrhcwo fir Ehi.h rhi\t(n ir is nsucd.IrhrllnorcnDloy3nyIrr\on iD rtrynrnmr
<br />\, $ I0 bcem suh,cd lo lhc qn(ss, !.nrcns io. hws of Calirirni!. rtrd isrc. rhar irI lh'old tt.o'm\uhjccr rorhc
<br />*orkc6' .onpcns.rion prcririons of Sdnnr :1700 of rk( tjtnr Codc. I shrll. nfih*ir h conrply *irh rho* tmvisi(,.s
<br />WARNIN(; Irrilurc !i, rcuc work$L .o'nFr{, ion ro1cr"!. r u.h$ful. dtrd rhrll subj.cl an cmpkiy.r ro
<br />.ill rnrc\ up k, on. huddrcJ rhou\rnd drnh^ 1s100,000
<br />:::.:JTEB:
<br />I hcrchy ltilrn unde, Fn,lry.r pdJxry rhxr I s6li..n{rt und.r rovili.n.rChnpicr 9 (.onnmm,n8 wirh Sdho ?01)0) oaDilhion 3
<br />oi rhc Duincs lnd A.rcsio.s.^dc. and m) lrcn{ i. in iullfnrcc andcryr
<br />6Auo 77
<br />{ts-'r {
<br />TONSIA]JI]IIONIENDI!.G.8.(iI'NT.I
<br />Ihcrl'yrnmurdcrpcndryofpcrjuryrhxrrhcrci\!(uNrrucri(nrbn{litrstrsun.yftrrhcpdrormMcorrhcworkturtrhi.hihisp.rnrih
<br />issucd (Scc :1097. Civ C ).
<br />&ILISd]iLIJ!!LISAIIA!
<br />I lR$y !fi-rnn undcr pcnalry of pcrjlr, otu ofrhc following dcclarari.n\:
<br />Dcnmlirion Pcmils Asbcslos Noriricalnrn ltdcr!l Rcsul.lions (1ilb.r(,. Pfir,
<br />Rcquncd L.ttcrolNolili. ion
<br />I r.!rilyrhxr r1[ lrdrrrlr.phrii, r 'rgxnl,nt r\l[n.\'cnDrxlr'. drrnt,t,
<br />'cxhlc
<br />t) rhi! fr'].rcr
<br />l.drir! rlr l luvcrcrd rlris r IrArrt'.an+lywirhnllCirtrtrdC.unry
<br />onlinrn.cs rnd S' c ksr rclnlins nc\olrhi\Cirt id Counry n, c[$ uFnrrl..
<br />rhovc f,r n cd F'Fnylor
<br />\ppUunl or \s.nl Sirnnlu '^-,/'E-!K
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />F ramrng
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ir/asonry
<br />Pool Fence
<br />T-Bar
<br />Handi cap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Ceftif .
<br />A
<br />FINAL 1-./r v.\.1.it.
<br />Certificate of Occu an
<br />Notes, Remarks, Etc
<br />BUILDING- INSPECTOR RECORD
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