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County af Lt�s Angel�s
,p���w�� � DEPARTMENT C}F PUBUC 1NGRKS BllILDING & SAFETY �IVISIpN -
Las Ang�ies Regionai Un�fo!m uode Program
STRUGTURAL C�BSERVATIaN REP{)RT FQRM
STRUCTtlR,4L OBa*ERVATION means the visue/obserratron af the sfrcrctural sysfem, for general conformance !a the
approved ptans errd spec�catlans, at srgnifrcent consmrc.ron sragas and at co,m,atetlon of the strucrurat system
Struc#u�9/0bservetron does nof rnGude or warre fhe r�s,aonsrtrllrN for'hg mspscfrpns reaurred Gy Sec,ron ?OB i704 or
othersect�ons of the Los Angetes Couniy Su�td�ng Gode ra"act+ons 7Db 4 5, 7T09;
# Re�ort Nc �i'
This repoK ancludes sIi oonstruction work throug� `�� day ot�v7't1�,.+.'G_____Pa9e tva _... ..._of�
Pro�ecf Rddress J q+ty SYuctural OCserver of Record (SQR} SOR Phane vo
-2. (,_ �- --�
Bu�Id�ng Fermrt No w rai t�bse^rat.on poservr Pra.essi nal Lic/Reg No Observer Phone Na
performed by �j{»tf,�, ��,p _ ao
t}83ERVED STRUG7URA� Ef.EMENTS AND TN IR C NNECTiONS
FOU�'JDATIdN WALL FRAMES FIQQR CLEt�ENT9tCC7NNECTIQN
OBSERVATION �OCATIJN
ng, Stem O Concrete O Steel Moment Fra�ne 7 �oncrete , �� ��p�� t�t2-
L� Mat a ❑ Maspnry ❑ S!ee!Breced Frame p $teal Deck [�'.�lZ-��«- ��jf-7' p�
a�s n Piles. C Wood � Concre�e �1�oment � YJaod —7'�'.t (�,s" liTt�7�'C.--
Grade$e Frame �� ���
etaming foundati G Others D `r7asorry VVail ❑ qt7ers �, �7
Hdls Anchors Frame � t"�"�-� �S
C�Q � Otners
'ta� �,tnu
NOTEO DEFIClENG1ES wlth tha prbposed correspondmg correcuve aotians with respect fo general
conformance vrlth ths appravad plans ar ir, Lhe Icad path: (A firal repan by;he structura! apserve�which states k!��t
sIl observed deficienaes have been reso�ved is required before e;.ceptance of:he work by G�e buildin� cfflaais)
DECLAf{E TFIATTHE FOLl.6WtNG STATEMENTS�_='RUe Tp THE BEST Of MY KNOWLEDGE
1, i AM THP ENGINEER OR ARCHI7ECT RETAINEG 5Y THE OYVNER TO 8E IN RE5PONS18LE -
CHARGE fOR THE BPRUCTURAL D85`cR�:'}.TION IN ACCORDANC� TH THE /Fr �` - `-," "+,
REQUIREMENTS OF TNE QOUNTY OF I,OS ANGE!ES G� B� ��t� r� '" " . ,-
(�Qj� vr. • ,
2 i, OR AHOTHER ENGINEER OR ARCHITECT N'HO i HAYE DESIGMA E7 b ABOYE AND 19 j +
UNOER MY RESPC+NSI6LE CHAftGE, HAS �:4FOR:t;'e� TNE REQUIFiED SITE YtS3T5 AT I
EACH 5tpNlFlCANT CONSTRUCTtON 9TAGE TO YERI'fY IF THE STRUCTURE IS IM ,
GENERAL CQNPORMAMCE WI7H aPPROV=_�'a��.n�s a.no saec���canoNs, � �-
�
� ALL NOTBD pEF1CtENCJ65 WHICH REMhIN T4 8E GORRECTE�HAVE BEEN INDiGATEO - / • �- �
�� - , ���°�/�
neo�e, `�,'-'. '°� ,� �
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4. I RECdMMENO THAT ACCEFTANCE CF Th:. STRUCTURG.L SYSTEMS BY THE C4UNTY �"ti,'��'��,:.,-^`
OF L6S AHOEt�E$ BE WtTHHEC6 VNTIL Atl. OB9ERVED DEFICIEkCIE5 ARE (
CORREGTED,
�fi<� �� f'�ff � (S7FMP 4F 5'RUCTU4A�08SERVER)
SIGNATURE OF�"TRIJGT OBSERvcn D-T�
VD•sicn 1 6 t2008;ACBC} Jan s0 3Ci�8
�. Gounty of L.as Ange3es
PuaucwaaKs �EPARTMENT OF P1JBLIC Wt}RKS BUILDING & SAFETY QIVISIflPI
Los Angeles Regfonal Uniform Gode Program
STRUC'fURAL C?88ERVATI{')N REPORT FC1RM
STRUCTtIRAL OBSERVATtQN means fhe vrsuaJ observatrorr of fhe structurat system, tor generat t�nfc�rmsnce to the
approvad p�ana and spec�catrons, at stgn+frcan!consfn�ctror+sfages and at completron of the strvcturat sysfam
SU�rctural observahart does not mctude or we�ve the responsrb�hfy tor the rnspec#�ons required by Sectron 108, 17Q4 or
other sacLons ot ihe Las Angeles County Burldrng Code {Sechons 1Q8 4 5, t 709)
Report No
Th�s repart mcludes all construet�an work through 22�nday of , O,L�Page Na �_af 1
—r—
Pro)ed Address }���p �,r� SUvctural 4bserver of Recard (SOR) SOR Phane No
Sa 1..C�'�Z- .-,�$3
8ui dmg Permit Na 5 ructurai Observat�on Qbservr rofessiana4�ic fReg No Observer P ane No
perfortnedby UN �-�'1 �' �l ^ �"9Q�i
OBSERVED STRUCTURAI.ELEMENTS AND 7HEIR CONNECTItiN3
FQUNDATION WA�� FRAMES F�ppR ELEMENTS/CONNECTION
OBSERVATI4N LOCATIQN
Faottng,Stem Walls ❑ ncrete O Steel Moment Fra ❑ Concrete -� �., U.p.u,5 �Z
at Foundatron Cl Ma onry ❑ eel Braced F e Steel 0 dc /��i�-� �({I� �{o�
❑Cai n,Pile , p Wo 0 Con te Mo nt '� ao ,l.¢�f t�- �,�j�/
Grade s Frame f� �c/� �. ..{�.r�
t�Retai g Fo tion ❑ rs ❑ Masonry 11 O rs �� ����
ide Speaa)An rs Frame �;,�
Others p�j f ❑ t? rs `� � c!�
NOTED DEFIOlENC1ES witlr the proposad correspanding correcGve act�ans w�th re�pect ta ganeral
con#ormance wtth the approved plsns or in the Iaad path• (A finak repart by the sVucturai observar wh�ch states that
aIl observed deffaenaes have been resolved �s required before acceptance qf tfie wark by�e butlding offieeals}
Cwa i� trt
�^.- + V
a tir�
t DECUIRE THATTHE f�LCOWING STATEMEHTS ARE TRt1E TQ THE BEST OF dIY KNOWLED6E
'i I AMTiiE EN4INEER OR ARCHtTE4T RETAINED BY THE OWNER TO 8E EN RESPONSIBLE
CNARGE FOR TH6 STRUCTURAL 08SERYATION IN ACCOR6ANGE{�W,IiH THE r"{���+Q
REQUIREMENT9 OF TI#E COUN'TY OF LOS AMGECES ('w-/'R( �� f��,80 � ^�l�,}�I f+����C�
2. 1, C11t ANOTH£R EHGINEER OR ARGHITECT YMHO I HAVE DESIGNATED d YE AND IS r��`�'tJ�� �'"S" �("),
UHOER MY RESPCtNSI6LE CHAR6E,HAS PERFORMED T4iE REQUIRED SITE YISITS AT = �rj Y�} ^��.'.
EACH 916NIFICANT CON9TRLtCT10N �7'AGE TO VERITY IF THE STRUCTUt2E IS IN ; � �� � 5�593 �
GENERAL Gt?NFORMANCE V41TH ARPIiQYEO PLANS AND 8PECIFtCAT10NS,
3. ALL NOTED DEFlCtENCiES Wt�CH REMAIN TO BE CORRECTED HAVE BEEN INDICATED b 1
ABOVE� ��' ��!
T� iv G ,�w�
4, f RECOMMEND iHAT AGCEPTANCE OF THE STRUCTURAL 9Y3TEMS 8V THE C4UNTY ` �
QF CQ8 ANOELES 8E WITHNELD UNTit ALL Q@SERVED �EFlCIENCIES ARE � �
CORRECTE6 /� P ��
_ f ,f�''�_,.,.•�"�� O -{ J �'"'I���'7iPt S" {STAMP OF S7RUCTU 46SERVER)
SIGNA7UREOFSTRU�URA1.08SERYfR DA
Version i 0(2008 LAC@C} Jan 102W8
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SPi3GiAI.ASPt77CY INSPBC'TUBS Ttb1E SHEBT 8c RBF'l7BT"
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Builduig Perunt No PR 14-3524 Peam�t Dete 9l12f14 Job Number �
Jobldmafic�an R�da�ceAdcii�io� Address a�asne�m�s���n,�damcn9�zas
C#en+e�a1 Conuactar DWS Cons�uctwn Addtess 6�9 S Stato Collega Slvd StaD Fatimon CA 9283 t —
Sub Conaai:tor Urb�OasWs Cansulung Addresa
Etsgmeer! Lee 8c Lee Suucturat Engw ,e�� Add[e�a ss3o w�vhuc 8ivd su aao[m+ange�,cn 400io
Ty�,eE Of ii€Or�: RCiTtf�o�d C;amcncGe [Q Meson�° C1 T�-TCris�lc BOlt+ng ❑
C}ther Firepmofing ❑ Weldmg ❑ Ultrasonie Teskang ❑
� Welder � Gertficat�on No. Welder Certification No
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4)A!1 cbncaete wes�Iaced by meana of�sa tazlgazwg ta a gravet�ump az�d wes consoUdated bY n'braqon mrh a 1•atmger �
�LAc�nans P��d ueev_�ade besm,foonn�and s3ab on gradn at r�r cif'reatdence snd new cohunn Ded faottt�far roof _
cxtr.neion et Eani af rssAdence
L�dN, Ttme, Amb temp, M�c tcmp, 51ump Tnmdct�; Ticketq, £'ump�asise Iocauun _
i 733am 68 84 A-1/4" 1520 93862i3 lrLdll3rdCN'Ioadlst�wArad4beaiu
Nnte Va�66od rdafiotcement wav exiCnded 24"Pase tlpe csearta af twNemn._at r�ade baun kcadon p�S-5/8_�nar w omrrete
Wark was done as per plans azui the spec�caaons to ehe t�esc of my tarou�ed.ge _ ___._
InaDecC4r_Seam Weas�ren
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wgmasr tx ao�tactot
VERIFY TI�IE ONLY
Re�ec�1 T�ePu�Y B s S�gned � ���J� �9�,���,�,,,��_ I i7 Na i0b�823 LA County�l i7?
Approved By :,{,.�, _.� ��F��Y
� Professional Special lnspectioe�, Ir�c.
39?Amberwick Ln.Brea,GA.92821�Fh.714-833-1792#PmfessionalSpeaaUnspecaon(6},gmail.cam
SPEC7AL DEFUTY INSPECTORS TIME SHEET& REPpR`T
oe��or eu���a smseey
crcyor Diamond Bar
Bufldang Pernut No 201A-279 Perm�t Date Job Numher
Jab Identificatx�n Res�deni�al AddiUon Address 2]350 Clurpusg Sparrow Rd Duunand Bar_CA
Genaral Contrac:tnr DWS Gonstnicti� Address
Sub Cantractar Address
Engweer L.ee&Lee Swctural Engmeenng Address 3550 W�lslure Blvd STE 4$0 LA, CA
Type of Work Re�nforced Concrete � Masonry � Iii-Tensale Boltmg p
Other Epo�cy Ftreproofing ❑ Weldmg ❑ Ultrasomc Testmg ❑
Welder Certif�cakion No Weider Cert��cat�an No
Special Deputy I n s p e c t � o n R e p o r t paxe o9n7na
1 )Provided v�sual mspect�on for the dnllmg of holes for#5 rebar epo�cy dowels The holes ware dnlled to a depW of 6"and were
brushed and blown ciean before the epoxy was in�ected The holes were spaced at_16"O C 7'he epo�ey usetf was 5�mpson Set XP
The EXP on lhe epoxy was 1/2015 Ttus work was done per Extenor Shear Wali Sectron Dekail 1/S-5 The dekail called for#4 dowels
but there was another set of fotting dowels to be placed tlwt calleA for#5 bars so the cantractor dec�ded to use#5 through out
T'he Foabng daweis were also dnlled to a depth of 6"and were btushed and blown cleap as well Same epony was t�sed Tlus wndc
dane per the Ex�s�mg and New fooLng Dowet CAnnecuons de[ail 2(S-5
Wozk in pmgress
Wark done per ihe approved plan less ihe#5 bars for the Shear Walt Epoxy Dowets
Inspector Ryan McBnde
DAILY Nt�URS Wt?R10EC�
Monday Tuesday Wecinesday Tht�tsday Fntiay Saturday Sunday
;straight Tsme 4
Tvne�Half
_...........................
;Dauble Tune
All mspectran is taaseci�a 4 hottt mmimum,over 4 hou��s an 8 hours mmunum AtJ iab work necesstuy to complatc�n�trons}nl]bee paid by
OWRCI,C[igSItCC7 4[C4Il�IHC�47
YERI[�Y TI14�ONLY
,
Regtstered Deputy Bmldmg Inspectcrr s S�gtad Repu�t �""K`�'"�',� ""��--^'—'> I D No i2844&?
Approved 8y Gompany
/�j/� �■�■r� �
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. # # ; . . . ;
09/l2/]4
Project: Residential Building
Address:2i 350 Chi�p�ng Sparraw Rosd, L?iaznand Bar,CA
Attention: Dav�d,DWS Conslruction
Subject: Ma.cirnum Dry Densrty and Clptimum Moisture of Sods
Sample Number: SS-201-3U14
Sample Location: CMsite
Reference to yaur request,a soil sample was picked up and brought ta our laboratary on
Septernber 1 l,2dt4 frorn the�bove subject pro�ect and performed ma2cimum dry density
and oppmum m�iskure tesk� in accordance w�th ASTM D 1557.
1fie obtained results as shawn belaw wilt serve as the reference proctor curve values in
the determination of rel�tive com�mckion.
*SOTL llESCItIPTION: Light Brnws Sandy Sitty Clay
MAXiMCtM DRY llENSITY: 124.01bstfN
t1PT�4t[Ih1 MOIS'I'(TI2E: 8.5°lo
Should you have any questions regarding this report,ar need further assista:�ce,
please call
Sincereiy,
fessianal Speci�l In�pection,3nc.
�---- __--._.,,,
Ryan McBride
*399 Amberwwk Ln Brea,CA 92821 PH (714)833-1792'
*Profess�onalSpec�allnspectionQa Gmail com•
� ,' Southv� t Ir tion and T ting, Inc.
� 441 Commerciai Way, La Habra, Ca 31
(562) 941-2990 • (714) 526-8441 • Faz(562) 946-0026
DAILY COMPACTION REPORT
Job Name DENNY LO RESIDENCE Date 09.11.14 Jab No Misc
Job Addresa 21350 CHIRPPING Sparrows Rd C�ty DIAMOND BAR
Pertnrt No. 91765 Issued By Diamond Bar
Ge �I Contractor DWS CONS7RUCTiON Greding Contractor SAME
/ of Inspection FOOTINGS Sods Inspector/Techniaan ]ose Rodnguez
EqwpmentUsed
LAB DATA
Proctor No Sam le Source Soils Descri tlon and USCS O timum Molature Mazimum Densi
1 NaGve �ght Brown Fine to Medium Sand w/gravel B 5 124 00
SUMMARY OF OPERATIONS
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TEST PLOT LOCATION S
1 Arrived at�ob site to perform densiry testing along proposed fooGngs all locations tested achieved a minimum of 95%
compaction reqwred by contractor FooGngs were randomly probe tested All locations tested were found to be firm dense
and unyielding
A= Below Existln As halt DENSITY TEST DATA
Teat Test Approximete Approxlmate FIII Proctor Dry Percent Percent Spealfled Pass/
No Locatlon Elevatlon Thickness No Densl Molsture Com actlon Com acdon Fall
1 See sketch above -4 0� Bottom 1 118 B 8.4 95.0 95% P
2 See sketch above 'Z� Bottom 1 118.8 8.7 95 B 95°� P
3 See sketch above 'Z� Bottom 1 120 5 B 2 97.2 95% P
CERTIFICATION OF COMPLIANCE CONTINUED ON � pAGE OF
NEXT PAGE
I I /CERTIFV 7HAT I HAVE OBSERVED T07HE BEST OF MV KNOWLEDGE ALL TIME IN TIME REG HOURS O.T. HOURS SAMPLES
OFTHEABOVEREPORTEDWORKUNLESSOTHE SENOTED IHAVEFOUNDTHIS OUT
WORK TO COMPLV W17H THE APP ED P ,SPECIFICATION,AND APPLICABLE
SECTION OF THE GOVERNING ING J OO i l OO 4 O N A
SIG OF SOILS INS ECTOR/TECHNICIAN
APPROVED
Solls 5307193 ICC sv
SPECIALTY NO AGENCY PROJECTSUPERINTENDENT
. 1
�� dg+� I.osAngeles Regionai Uni#orm LAE2UCP
�..,.c.ra.�um..owm Code Pragram ' "
STRUCTURAI. OBSERVATION REP�RT FORM
STRUCTURAt OESERVAflON mearts fhe vrsua!obaenr�t�orr of the strudurat system,for generat conformance ta ftre approued
ptarrs and specficatrons,af srgnfircani carstrucGon stages arrd at completron atthe strucfurst system SWctural observefron does
ttOf 77tCtttde pf W2NQ fh81HS R5�61j t6f fj781RS CfIOilS U8$L/b $6C60n 108 ?7i?J OF pth9�S8CU4ltS Ol thB COd6
�� /'�,, � Report Na
Th�s re ort mcludes�II construction wo�tc throu h 1�1 da of tr�^" 24 P e Na of
Projed Address StrucWrel Dbserver W Resn (S6R) Phona No SIXt
�- 3f� �i?r � � o�sl��r' /ax�Gi ott �CL� � �S"-�o2"'i
BulldinB��Na SUvcN Observatiar��eriannecf by Prot�sionel UclReg Na atQbearver No �Obaerver
.�—� OGG "��7
089EPYE0 BipUCtUMt EGEYEMi$�ltff&i CAM'lEGTUMB
FOUNpAT16N WALL FRAMES FLQOR FQRTIQN 08SERVED,IF t#GT SMHQtE
� Footing,Stem Wetis, �Concrete ❑Steel Manenf Freme ❑Concrete �( ,G
�Mat Faundation O Masonry D Steel 8raced Frame ❑Steei �a
�Ca�sson,Piles,C,rade Be3ms Wood ❑Concrete MomeM Frame �Wo�i
� RetammgFoundatlon DOther ❑MasonryWallFrame ❑4thars �Q� �l�1 O,
H�Ilside 3pec�aY Mchors �
�Others �4thars .�/D
QBSERYED DEFICIENCIES �/ �
I RECIARE THAT THE F41.lOWING STATEMENTS AR£TRUE T4THE�STOF MY KNOWLEDGE ��q�
7 I AM 71iE ENGINEER OR ARCHtTECT RETAINED BY THE OWNEFt TO BE IN RESPWJSIBLE �4s"`—""
GNARGEFOR7HESTRUCTVRAt08SERVATIQNIHACC4RpAMCEWRFiTHEREQUIREMENTSr � �{jC ��
6F THE CRY OF LQS ANGELE3
2 I,OR ANOTHER ENGINEER OR ARCHRECT WX6I HAVE�ShGNAT�A86VE AND IS UNDER � N6.3B21 �
MY RESPQNSIBLE CHARGE, HAS PERFORMED THE AEpU1RED St1E V18tT8 AT EACH *, �� „k,
SIGNIFfCANT CONSTAUCTION STAGE TO VERffY IF TNE S7RUCTURE IS IN GENERAL
CONFORhIAHCE WITH APPROVED PCANS AND SPECIFICATIOHS, �,.�� Q,�.
9 A�l DEFICIENCIES WNICH REMAIN TO BE CORRECTED HAYE BEEN IN�ICATED ABOItE, �Qp CA{,\�^'
4 i RECOMMEND TMAT ACCEPTANCE OF THE STRUCTURAL SY$TEMS BY TNE CITY�LOS
ANGEIES 9E WRHiiELD UNT7L ALL 085ERYE0 OEFICIEMCtES ARE CdRRECTED
_ ,I U/ _,�L'�j j STMMqFS�C�N.t16SERYFROF�
V"'",,,F J
SIGNATURE OATE
INfFom�OB(Pert 1I t� :2U63) wax Imbe ory
r�
DWS Construcfion
879 S State College Blvd 3te D
Fullerton Ca
(9p9) 261-50&2
Lic#953735
�
February 23, 2{}15 �"�,C�'�`� �
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C�ty of D�amot�d Bar
21810 Copley Dr
D�amond 8ar, CA 91765
RE: 20�50 Chirping Sparrow Rd., Diamond Bar,CA 91765
Permk#PR14-3524
Dear Sir
i, David W Smith, owner of DW5 Canxtruchon, am na Ionger the general oontraator for th�s property and
there are no fees due at th�s t�me
Thank you
�n�k�t�
�
Dav�f W Smrth,
DWS Gonstrucctron
dW51If
y�� CONTRACTORS STATE LIGEMSE BOARQ srnrE�cauFoa+�v,
9821 8usmess Park Oeite�Sacrama+b Ca�icmia 856ZJ GOvemOr EdrntaM G Bttam Jr
hi�i�Atldress P 6 Bmc 26006,SmamBnW�{;A 968Y9
5�321�CSlB{2762)
www ts�ce 8w'•ChetkT7reL�enseFtrst tm+
Exemption from Workers' Compensation
Beforc the CoMractas State ixense Board(CSLB}can issue a new I�snsa�remststa,ieacUva�.or renew en��sUttg I��e,Ure appl�caM
or I�cer�see must hava on fiie a Cerbfic�te ot Wrnkers'Cort�ense66ai Insurance or a Certificate of SeN-i�urence�.s�d by the D�rerdor ot
I�usUml Reiairons,or must ob�n an exert�tron by corrpiedng snd submrtbng ttus form
To ba exer�t iram waiaers'compensatron,an aR1���rt�r IKensee m�t submt th�s farm ta CSI.B,c�'tdy�r�under penelty of pepury that he
or ahe daes not emp(oy anyorre m e manrrer thai rs sub�eet to#re wotkers'carr�e�ai laws W Cahtamie (Sae Hus+nass a»G Prafesva�s
Cade Sachon Tt25 J
p0 NOT Sti6MTT TNIS FORM IF.
• You h8ve an inas�ve i�canse
• The i�nse qualfier�s a Respor�ble Menagng EmpbyOe{RME}
� Yau hotd a C-39 Roafirg Gsss�Catqn-�fi wMraGore wAh a G-39 Ftnpfirg dassfication are requrced by Sectwn 7125 to have a
Cerbfitate of Workers'Comperaa6on Insurance pr a Ce�iiflcate of Self•Insur�nce pn 61e w4h the Boarsl Contrmctors wkh a C38
Roafl�ciesalflcaqai ars nd e0glble tpr exempqOn Man workers'eampeneaflon
� You have empbyees
For exemptlon finm workeis'compensaSian,carrq�lete�II of ihe req�sted infprtna6w�m&etXwn i,dreck r,�nly rg�oflhe 4oxes m Sec�on 2,end
date and sgn the farm in SeGron 3
Pleeea lype or prhk rreatly grM IBgIWy In kkCk Or dark t�ug Ink.
SECTION 1 -REQUIRED BUSINESS NAME AND ADDRESS
8ustness Neme(es tt aifrently appeara on CStB records) 4lcenae or Apphcalwn Fee tiumber
D W Smith Construction 953735
Businass Mafiing Addrese(numberlstreet a P O boxj City State Zip Code
679 S State Coilege Blvd Ste D Fullertan CA 92831
Business Street Addrgss(number/eheet oMy-NO P O Gozes) City Stete Lp Cade
Budnesa Phane Number Buslness Fan Number Buelnese E-mail Addrnas
(909 ) 261-5082 ( } dwsconstruction2@aoi.com
❑ Cheek thie box f}the addreae el5pwn eppre Ie new CSLB wlli update your Iicemse/appl�cetlon bueinese atldreae ot record
SECTiON 2-REQUIREQ CHECK BOX
YOt!MUST CHECK g�Y Qt�OF THE BpXEB eELOW
8 4 do nnt empioy anyane m the manner aubjeet to the wpAcers'compeirseGon lews of Caldomia l7R
❑ 1 am an ou[-ol-atete cantracror,and I�not h�re emaayees whd res�le m Cal�torma (Yau must prmnde a cerificatb ot msurance iran yd+r
workers'campensabon msurar�e cemer m yovr harre state}
SEG710N 3-REpU1REi?SK3NATURE
I certl(y under panalty Of pe�ury under ihe lews o(tl�e State ot Calfiwn�a thet the Inhxmetit�n pmvaled an Ihzs exettpticn statert�nt re We and
ea.urste I undersfand that,u{mn empla�nng anyor�a�a man�r tbe#re aubJect to the workern'Cnmpenssbon lews atthe State of Gel�tmn�a,the
da�n of exertpt�ex�uted under Ifi�s fortn wdi no Iw�ger be valb I a�so ur�ierak�nd thsk,as soan aa 1 employ anya�aubJett ro the
Celdmn�a's work�s'cqrt�pensaUon lax�s,l mugt�taro a CeA�icste of Wptkars'Compe�esbon in$urence,sul,md tltiat csrtficese to CSLB wrthm
90 days o(ds afiecGre date,and conbnuuusly mamtam qre eaverege providetl by tFte oatMEcate m eccardstxe+vtth ihe�w i tuMat undereiand
that fadure io�mply wlth th�a r�unement�s grqunda far d�acpUnery ectwn (7tre deflrrRtao of pet�ury'�$tetkng a t+e whtJa urrder oath J
PALSIFlCATIOX 4F. Uf�NT I9 GRQUNOS FOR Ol&GIPLINAftY ACTiON
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