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<br />(Pieei2 us3 a black or b!,ie ink bal!-point pent
<br />ffi-$A}m
<br />,A}Hm
<br />PIt^1,,1 J & Bu'iJ,,1 ,J Agen;y
<br />l,) C, ,',: tl l,-ria,' P,r: t f :;; A,rne (
<br />PC B.:< lJ,J,Jr!l -11
<br />S:nt: A,''r, CA 9l'll
<br />(-llr iJ''5,J,)t)
<br />Srncke & CO
<br />AI arm Affidavit
<br />P r c1:':t AJ C,'e ; s
<br />Permit lrl ,.rrnber
<br />Prcperty Owner
<br />C o n tra;tJr:Lice ns? #
<br />S:::: :i Cat,i:,.;.it i":1,.i ,-_.; th"l . j.-,llr-, f .,j Car-5,_n nO,.r,; <i,j: {,1O, r,a'r.i j l.: in;t:il:l in r:;ide,.i.al
<br />b,.il,ji;rJi
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<br />'r--.-':r',:::'l 1,,l:ii sror(: l'f"'1j:^.1 cl,'5ci noncri,je I t'1'j. CB.l S-:':i:,:,r Rii-l 3 ani R3t1 3 3 jerrre
<br />tle r:,lr,ri':C loca:,,:n ;
<br />n 3,:th box --s belo,^/ musl be checl<:C :
<br />E Cr..r,r'", rnonoxj,j: r'aims:A,':,n;:rila,:l c,rlji:l : o; el,:it jle:pir'g l,':: irr ile irrr-elil:: vicjnl':/ oi
<br />5e,jr':,:n s lird ai;c,)n :rcn ler:i :i i:.c d'^/elltng A,arnr; ai-l i'?q,rir':d in bed,'c,lr-lri witil 3l;-flr:l
<br />a:ci,l;'rc-r j (i.: hol wr::i hlt:1r., cJ,)k:lp f lrna,ei,;r 3 ii;-3piace
<br />E S,rrol<e aiarnrs:A;: rr^si:,!t'j ir- :-t,:: r:1,),^") us;C i-tr ;leeprng, trr ?1,15 h.lll',vl/ culjide of a ;ie:cing
<br />(ooc', ?r^c orr :ach levei :i tle d ryellirB
<br />R.r','f i t-:(j de::cl)rj r''t,t'r be bll:1,"/-orerlt:d f ;r b,,ildi,rg; ryhe.: nO ini:riOr alt-'rllions are
<br />p-.rf,)r::e,1. ,r,ra,,.t''ir^ S,-rol<:J-! 1i3;-:i1j nTusico'rpl7 r,irrillr ,;1 3;pir,:lbie ;irnrj,r,'j j lt',-1 be a:,'oroveC
<br />b'7 [:e Scr:e Fir: t\lar:hail i;;i\li Ba:::r''7 iiie mu':t be l-l years
<br />I her:cy certtfT ti"ai I ar:, lie ccni-lc:Jr or tne pi?certl o'runer oi t:re lbo'ie prllect. I f"riiler-cert;fy
<br />that ;inoK,'aiari:r; and;er-5,)o rnon'),(,de:iar':ns ra'ie been inst.rlled in ccmpliance wrth the,3overntng
<br />Cc,j,:s and ha.re be'::. i:;i:,1 tc be f,-,irrclronai. l, arsc, he.eb,r ,:el'rrf'7 "t'3t 1 ,vvill rSlesi lle aiar"ns oer the
<br />man u itct;rer'' ; inst,-'.rci,on s
<br />Signatur z af/vd Dat z 6[t6
<br />(check o n e)tr L:cet ie,J Ccnii'ar:to:E Pr-o oeri I \/uner
<br />NOf: This;elf-certificzt:on is oni,/ used for prcject; that tffzct the EXTER|OR oi ne ;tructure. This
<br />pr)c2;i is'tpOlicabte CftrL{ to ptoi.c!; wherz dc.ess to the interior of the d,pelling by a Santt Ana
<br />lnspectcr is not rzquirzd.
<br />Ha.re ihrs completed fcrm an.l the job-c,rrC re*7il'y available on final inspectioni
<br />\+t^26zl
<br />a
<br />111 r/'11 i l^'! 1 - r '
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