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Home My WebLink About11-1427 � . �`_ CITY OF DIAMOND BAR � p / ::. DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �� 21825 Copley Drive,Diamond Bar,CA 91765 (909)839-7020 Fax(909)861-3ll7 Building Inspection Hotline(909)839-7027 PRESS '°�"� BUILDING PERMIT APPLICATION FIRMLY �� JOBSITE APPLICATI �`1� PERMIT p/C .. ADDRESS c�� SL.I' G�/� �� 1� DATE �1 NUMBER p ��- \Q4.2 '� ISSUE �s� TYPE CC APN LOT�T ACT DATE � d'�/ CONST. -Up p OWNER . o ADD SS � ZONING SETBACKS Z CITY f�A� IP TE . � � � FRONT pyy � g APPLICANT - ' TE - � SIDE/SIDE STREET RW p � CONTRAC�O � SIDE � o CTMRES Q� � ZIP� TEL. D PROPOSEDUSE Q�'-'�C"6l�r�ylf� WQ\� w ARCH/ENG/ � /��k�� z DESIGNER I tl � ADDRESS NO.DWEL. O. i NO. cn UNITS I STORIES BEDROOMS�� CITY ZIP TEL. N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION SFWADD/fiEM O p I HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT I AA1 E%EMPT FROM THE CONTRACTORS LI- Gflfe9B/C9fPOR W CENSEUWFORTHEFOLLOWINOREASON(SEC.7031.5BUSINESSANDPROFESSIONSCODE:ANYCITVOR (n U COUNTVWHICHREOUIRESAPERMRTOCANSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTqUC� W w TUflE,PRpR TO ITS ISSUANCE,ALSO REOUIRES hiE APPLICANT FOR SUCM PEflMIT TO FILE A SIONED W Patlo/Deck � STATEAIENT THA7 HE OR SHE IS LICENSED PURSUAN7 70 THE PqOVI510N5 OF THE CONTRAC70RS LI- � CENSE LAW(piADTER B(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO� � POOUSpe FESSIONS CODE)OR THAT HE OR SHE IS E%EMPT THEREFROM AN�THE BASIS FOR THE ALLEGED E%EMP- � TION.ANVVIOUTIONOFSECTION7031.SBVANVAPPIICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof A CML PENALTV OF NOT MORE hiAN FNE HUNDRED DOlURS(f500).): � ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOVEESWITHWAOESASTHEIRSOLECOMPENSATION, � COrtIfiIBfCIa1 Z WILL DO hiE WORKµD THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7M�,BU51- J � NE55 AND PROFESSIONS CODE:hiE CONTfiACTORS LICENSE UW OOES NOT APPLV TO AN OWNER OF � PROPERTY NT10 BUILOS OA IM7ROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR W THROUGH HIS OR HER ONM EMPLOYEES,PROVIDED THAT SUCH IMPqOVEMENTS ARE NOT INTENDED OR m Q OFFEREDFORS/�LEIF,FIOWEVER,7HEBUILDINOORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPIE- Z TION.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVINO THAT HE OR SHE DID NOT BUILD OR � IAIPROVE FOR THE PURPOSE OF SALE�. W ❑I,AS ONRJER OF THE PROPEHTY,AM E%CWSNELV CONTRACTINO WfTH LICENSED CONiRACTORS � TO CONSTRUCT THE PR0.IECT(SEC.7o1a,BUSINESS AN�PROFESSIONS CODE THE CONTRACTOqS LI- V81U8�1Of1 A0.1.ApEA W CENSE UW DOES NOTAPVLV TO AN OWNER OF A PROPERTV WHO BUILDS OR IMPROVES THEREON,AND � WHOCOMRACTSFORSUp1PHP1ECT3WITHACONTRACTOF(S�LICENSEDPURSUANTTOTHECONTRAG Q�J(�f.J7�Ty DESCRIPTION roas ucENse uw.�. FEE � ❑I AM EXEMPT UNDEH SEC. B.8 V.C.FOR TNIS REASON Q ?� U LL DATE OWNER ~ Z U � LICENSED CONTFACTORS DECLARATION w � I HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT I AM LICENSEO UNDER PROVISIONS OF CHAPTER � � Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF 7HE BUSINE55 AND PROFESSKKJS CODE,AND Z � �� W UCENSE IS IN FULL FORCE ANO EFFECT. 'j � J (� m � ICENSE C S LIC.NO. � r J V`� � � � V DATE � CONTRACT d LiJ � WORKERS'COMPENSATION DECLA ION ' Q U � I HEREBY AFFIRM UNDER VENALTV OF PERIURY ONE OF THE FOLLOWI DEClARA710N5: Z �z _I HAVE AND WILL MAMTAIN ACERTIFICATE OF CONSEMTO SELF-INSUPE FOR WORKERS' ¢ Q = � CONPENSATION,AS PROVIOED BV SECTION 370o OF THE LABOR CODE,FOR THE PERFORMMICE U OFTHE WORN FOR WHICH THIS 7ERMIT IS ISSUED. W � � w _I HAVE AND WILI MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION Q 370o OF THE LABOR CAOE,FOR THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS � ��/O • � ISSUED.MY WORKERS'CAMPENSATION INSURAtJCE CMRIER AND FOIICV NUMBEHAAE: CONSTRUCTION `-C j ` _ CARHIER PLAN REVIEW _ Z �� POLICV NUMBER ELECTRIC ¢ � (iT16SECT10NNE�NDTBE�1.Si.EfEDOF71-IEPEMIfTISFORONE{�.�DPEpppLLAiLS(f100)ORLESS} PLUMBING W Z I CERTIFV 7HAT IN THE PERFORMANCE OF THE WORN FOR WHIp1 THIS PERMIT IS ISSUED,I MECHANICAL C� SHALL NOT EMPLOV ANV PERSON IN ANV MANNER SO AS TO BECOME SU&IECT TO THE (/J WORKERS'COMPENSATION LAWS OF CALIFORNIA,qND AGREE THAT IF 1 SHOULD BECAME INSPECTION FEE SUBJECTTOTHEVIORKERS'COM7ENSATIONPROVISIONSOFSECTION37000FTHEUBOR A ' ' [ a s CODE,I SHALL FORTMNITH COMPLV WITH THOSE PROVISIONS. ISSUANCE �S o ( . 2_O p OATE: APPLICANT: SMIP W � WARNIN6:FAILURE TO SECURE WORKEFS'COMPENSATION CAVERAOE IS UNIAWFUL,AND SHALL BE ENERGY P/C � � SU&IECTANEMPLOVERTOCflIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT ' DOLURS(f70o,000),IN ADDITION TO THE COST OF CAMPENSATION,DAMAGES AS PROVIDED f-0R IN J SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEV'S FEES. w RETENTION FEE: .d O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: - 3� • � I HEREBV AFFIHM UNDER 7ENALTV OF PERJURV THAT THERE IS A CONSTRUCTION LENDWO AGENCY //�J�/7�� FOR THE PERFORMANCE OF7NE WORK FOR WHICH THIS PERAIIT IS ISSUED(SEC.30B7,CIV.C.). W^=" . Z W � LENDER'S NAA/E � LENDER'SADDRESS W I CERTIFV 1HAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATqN IS CARRECT, TOTAL F E ES Y/�+ L� � I AOREE TO COMPLV WITH ALL CfTY AND CAUNTY ORDINANCES/WD STATE UWS REUTINO TO BUILDINO � CONSTRUCTION,AND HEREBY AUT}IORIZE REPRESENTATI ES OF THIS COUNTV TO EMER UPON THE Z ABOVE�MENTIONED PROPERTV FOR INSPECTION PURPOS s. COMMENTS ' � '\ . V1� J � m V�iMITT AME(P INT) � � � � v J / � IONA O P . ITT 7E - � RECPT.NO. PAID BY ' . VALIDATION WHITE—DepaAment Copy,YELLOW�inence Copy,PINK—Assessor Capy,GOLDENROD—Flle Copy,GREEN—Applicanl's Copy CI�Y OF DI�,f�iOND �AFi • . + � t INSP�CI'IOi� �ECORD �'��:`4�n]�pCsC�4QOG�l o �`��'ti QI�I�PGC5�G3 � DGr}}�L�C�4D�' ��Z��' !' � SET BACK FLOOR JOIST � FTGS/FORMS/STEEL / FHA REQMTS ELECTRIC GROUND UNDER FLOOR DUCT GROUND PLUMBING UNOER FLOOR CONDUIT SLAB GRADE FIREPLACE FOUNDATION TEMP POWER FIREPLACE BOND BEAM WATER SERVICE MID H'T. BOND BEAM ROOF SHEATHING - 8 FT. BOND BEAM FRAMINGNENTILATION FINAL BOND BEAM � � N , ROOF COVER PRE-GRADING ROUGH HEATING BENCHING ROUGH ELECTRIC ROUGH GRADING ROUGH PLUMBING FINISH GRADING SHOWER/TUB TEST POOL ELECTRIC EXT. LATH/SIDING POOL FENCING WALL INSULATION POOL FINAL CEILING INSULATIOPI OFF SITE IMPS. DRYWALL NAILING DEDICATIONS SEWER FINAL ENG. SEPTIC TANK LANDSCAPE/IRRIG. SEEP PIT/L.L. ON SITE IMPS. GAS AIR TEST FINAL ZONING FINAL CONST. FIRE DEPT. FINA� FINAL HEATING � HEALTH DEPT. FINAL FINAL ELECTRIC DEV. FEES PAID FINAL PLUMBING ENERGY ��. COMMENTS � ��f 5 a a.�/� Q l� _ 1 SEPTIC TANK SIZE SEEP PIT/U SIZE a � Q `r�": �,ti�k sA��j Q �� • , , CITY OF DIAMOND BAR I � �- `--"-�� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 Copley Drive,Diamond Bar,CA 91765 (909)839-7020 Fax(909)861-3ll7 Building Inspection Hotline(909)839-7027 PRESS '"""� BUILDING PERMIT APPLICATION FIRMLY oN JOBSITE j��I l APPLICATION PERMIT � p/C ADDRESS_"'C.� 1 I � ��r�S �� DATE � �� NUMBE #� 1�-\O � ISSUE TYPE OCC APN LOT TRACT DATE / I l�I� � I CONST. GROUP p OWNER p ADDRESS ZONING SETBACKS z CITY ZIP TEL. FRONT RW O o APPLICANT TEL. REAR � zd SIDE/SIDE STREET RW ❑ � CONTRACTOR O /�-�AT( SIDE � o CDDRESS Z�P TE� � 1 pROPOSED US M � I O `^J �' � o ARCWENG/ z DESIGNER w NO.DWEL. ( NO. a ADDRESS NO. � UNITS STORIES , / gEDROOMS � CITY ZIP TEL. N DESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATION . O OWNER-BUILDER DECLARATION SF ADD EM � .�S Q I HEREBV AFFIRM UNDER PENAL7Y OF PE0.NRV THAT I AM E%EMPT FROM THE CONTRACTORS LI- G9f8 B/CB W CENSEUWFORTHEFOLLOWINOREASON(SEC.7031.5BUSINESSANDPFOFESSIONSCODE:ANYCITVOR (n 9 �rt C� CAUNTYVh11CHRE0UIRESAPERMITTOCON57AUCT,A�TER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUC� PatlO/DBCI( W 7URE.PRIOR TO ITS ISSUANCE,AL50 REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED w � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTOFiS L6 � CENSE LAW(CHAPTER Y(COMMENCWO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINE55 AND PRO� LL' POOI/SP8 FESSIONS CODE)OR 7HAT HE OR SHE IS EXEMPT iHEREFROAI AND THE BASIS FOR THE ALLEGED EXEMP- � TION.ANV VIOIATION OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SU&lECTS THE APPIICANT TO Z qe-Roof � A CML PENALTV OF NOT MORE THAN FIVE HUNDRED DOLLAHS(f500)J: � ❑I,ASONMEROFTHEPROPERTY,ORMVEMPLOVEESWITHWAOESASTHEIRSOLECAMPENSATION, � COrt1rtIBfC18I Z WILL DO THE WORK,AND THE STRUCNRE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7M�,BUSI- J - � NESS AND PROFESSIONS CODE:THE CONTRACTORS UCENSE UW DOES NOT APPLV TO AN OWNER OF � i PROPERTV WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORN HIMSELFOR HERSELF OR Q THROUGH HIS OR HER ONRJ EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m 0 OFFEqEDFOR5PLEIF,HOWEVERTMEBUILDINaORIMPROVEMENTIS50lDWfTHINONEVEAROFCOMPLE- Z TION.THE OWNER-BUILDER WILL MAVE THE BURDEN OF PROVWO THAT HE OR SHE DID NOT BUIID OR . � IMPROVE FOR 7HE PURPOSE OF SALE). � . �yJ ❑4�OWNER OF THE PROPEHf�;AM EXCLUSIVELY CONTRACTINO WfTM LICENSED CONTMCTORS 1��Q r� � � TO CONSTRUCT TME PR0.IECT(SEC.7041,BUSINESS AND PROFESSIONS CODE:TNE CANTRACTORS LI- V8IU3fIOf1 � W CENSELAWDOESNOTAPPIVTOANONRJEROFAPROPERTVWHOBUILDSOqIMPROVESTHERC-0N,AND � — � - � —��ARE'°' � WFIOCANTRACTSFORSUCHPR0.)ECTSWITHACONTRACTOR(S)UCENSEDPURSUANTTOTHECOMRAC- OUANTITY DESCRIPTION FEE TORS UCENSE LAW.). ❑1 AM EXEMPT UNDER SEC. "'� �,J 0 B.8 P.C.FOR THIS REASON Q D U � DA7E OWNER H � � LICENSED CONTRACTORS DECLARATION W � 1 HEREBY AFFIRM UNDER PEN�LN OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTEP � � � � Y(COMMENCIN(3 WITH SECTION 7000)OF OIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE.AND Z OMY UCENSE IS IN FULL FORCE AND EFFECT. �� LICENSE C S LIC.NO. � V OATE �� CONTRAGTOR a W � WORKERS'COMPENSATION DECLARATION Q N I HEREBYAFFIRM UNDER PENALTY OF PERIURV ONE OFTHE FOILOWING DECUAATIONS: U � Z � _I NAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF�INSURE FOR WORKERS' a Z 2 Q COMPENSATION,AS PROVI�ED BV SECTION 37000GTHE IABOR COOE,FOR THE PERFORMANCE U OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED. W � '/ � �I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REOUIRED BY SECTION Q 370aOFTHELABORCODE,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS ��0.� ISSUED.MV WORNERS'CAMPENSATION INSURANCE CAARIER AND POLICY NUMBER ARE: CONSTRUCTION � CARRIER PLAN REVIEW �� . �4• POLICV NUMBER ¢ ELECTRIC jb ,•� 0 (IlCSSECIIONNE�NDTBE00MR.EfIDOF7HEPEFUYTISFOqONEF►11�Di7EDDOLLAiLSR��)��1 PLUMBING �j�, (p� W Z �CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I MECHANICAL C.�} SHALL NOT EMPLOV ANY PERSON IN ANV MANNER SO AS TO BECOME SU&IECT TO THE (n WORNERS'CAMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHWLDBECOME INSPECTIONFEE SUBJECTTOTHEWORKERS'COMPENSATIONPqOVI510NSOFSECTION37000FTHEUBOR �� O CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE p DATE: APPLICANT. SMIP `, �� w ENERGYP/C �V �`14- J WARNINO:FAILURE TO SECUFE WORKERS'COMPENSATION CqVERAGE IS UNUWFUL,AND SHALL BE 1 J �y SU&IECTANEMPLOVERTOCRIMINALPENALTIESANOCIVILFINESUPTOONEHUNDREDTMOUSAND ENERGYPERMIT O( �. Q DOLLARS(f100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAQES AS PROVIDED f-0R IN J SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEVS FEES. ��- � W RETENTION FEE: _ O CONSTRUCTION LENDING AGENCY PRE•ALT FEE: � I HEREBV AFFIRM UNDER PENALTV OF PERJURV 7HAT THERE IS A CONSTRUCTION LENDING AOENCY �F � `O� � � FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3oG7,CIV.C.). Z W �� LENDERSNAME I— LENDER'SADDRESS � w I CERTIFY 7HAT I HAVE READ TNIS APPLICATION AND STATE THAT THE ABOVE INFORMATqN IS CARRECT. TOTAL FE ES `�1C7� � � �.�. ``l 4. `� � I AOREE TO COMPLV WITN ALL GTV ANO COUNTY ORDINANCES AND STATE UWS FEUTING TO BUILDING � CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO EMER UPON THE Z ABOVE�MEN710NED PROPER FOR INSPECTKKJ PUR ES. COMMENTS � r� �DjZ � � m PERMI E(PRI � � ¢ L "-' G ��S \\ �nn � 510 R F PE E DA7 � RECPT.NO. PAID BY VALIDATION WH —Department Copy,YELLOW—Finence Copy,PINK—Aasessa Copy,GOLDE, OD—File Copy,GREEN—Applicant's Copy CI�V OF Dl.a►�/iOND �,�Fi ? �� , �, � � I�S��CT60� R�COR� �:. � , „ � ��;..`:Q��3QGC�400a �.� �,G�� ,��` �t,�]�P�G'41�1� � OG�J�PL�OOa DG�QI� . Da�pGC�40G3': SET BACK • '� FLOOR JOIST FTGS/FORMS/STEEL � FHA REQMTS ELECTRIC GROUND UNDER FLOOR DUCT GROUNQ PLUMBING '�� '� � UNDER FLOOR C�NDUIT SLAB GRADE �l 1j� ! FIREPLACE FOUNDATION TEMP POWER ~� FIREPLACE BOND BEAM WATER SERVICE MID H'T. BOND BEAM ROOF SHEATHING 8 FT. BOND BEAM FRAMINGNENTILATION g � VL _ FINAL BOND BEAM ROOF COVER t - PRE-GRADING ROUGH HEATING �� `� BENCHING ROUGH ELECTRIC ROUGH GRADING ROUGH PLUMBING FINISH GRADING SHOWER/TUB TEST , POOL ELECTRIC EXT. LATH/SIDING ` V 1��12_ POOL FENCING WALL INSULATION POOL FINAL CEILING INSULATION - OFF SITE IMPS. DRYWALL NAILING L� DEDICATIONS SEWER FINAL ENG. SEPTIC TANK LANDSCAPE/IRRIG. SEEP PIT/L.L. ON SITE IMPS. GAS AIR TEST FINAL ZONING FINAL CONST. FIRE DEPT. FINAL F►NAL HEATING HEALTH DEPT. FINAL FINAL ELECTRIC 2 _ � DEV. FEES PAID FINAL PLUMBING ENERGY ��'��e ' t�J✓ S�c�✓ b�f . t��I�_� �`"'�.� COMMENTS �,� � '-(�� ` �-�� SEPTIC TANK SIZE SEEP PIT/U SIZE a :e� � r x .°r a� � � � C;l.�--� G,�. ��rj�cv�� l� , Los Angeles Uniform Code Program �o,��s��«��., ' Uniform Ptocedure 1-7: Specio) Inspedions LAR U C P . � V�o.w.coo��.00�� I SPECIAL INSPECTION REPORT ❑ DISCREPAHC7 �CONFORMANCE Ab dixreparxies shar De brougM to Ihe irrrr+ediele atbention o(Ne H work oonfortrn!o approved desgn and wds requireme�b, subrttit tlrs Contractnr ta co�rection. N corrections aro not mad� in a timely ►eDort b Budding Departrt�d ana oopies to Contracta,EngineerlArchited manner. fhis ropat sDaU be used as e disttepancy notics. Subnit ot retord �d Ov�ner no latet tnan fhe business dal► Idtowing �►e tha o�ginal to Bw'ldinp Departrnent ard copies to Contrac�a. cancknion of fha speaal inspection. Fcr inspections greater than 5 da�rs Enaineer/Archited of reoord and Owner. duration.wDrtut a conhxmance reoort al�least once everv week. This is a: �P� ress R O Fna! Repo�t Report No.: � Pa a No. of � �am...: a v�o;aa ZW t 1 ,:�t�;�e�S' ,4��/ .;r��e • �f �. weM Murt�D�r. . � d Rem� �j _ l cu� Z �� . � rY'�� S � ' �I Wnr d Spwr In�pa¢�or , q�p�tr�lYon Pk+n+Ew� 'f�n�r: � �/�,�[%N►Jd�i �r r�t� �%�- �C//3�.�,i`/.G� -7j;�•.3�,j'��'�.� G �'`��z` �- Typ�of Inap�cdon: . O Reinloroed Concrete O Structurul Maaonry O Pilin�, Piers and Caiasona O Smoks Contrd , O Prestressed/Post-tensfo�ed O Bolta In ConcretelMesonry O Excavation and Filb ❑ EnergY Comptianoe D SholcxetelGunite O Strudu►ai Weldir►q O Spray-Applied Firo Proofing D Tespng Reports I O Insulating Concrete/Gyperete ❑ High Strength 8dtin� (�Other ,�c�S Ll,�/2L��v r�1 �nt�. Tlms Tirru� D te Art�tr DapaRed DescrfptjonI an�Locatlon of Worlc I�spacted �/'?•�✓�� ,��r/�P�� /�,�7�i��_� i� �Z. �l1____1?��'/Yst�'j � ----T lt�.�:�[9�`�� /it/ � l�B ,��,��i� [3,i�� C� � 1t/ .��T—f� Tl�c� �L._ .`��,/r�/�= -I% Remarks��c'� �iZl�/2-� c�'��-C-� 1U� ��-G�lC- g° �7� `� 'Z'� c_ I HEREBY OECLARE TW1T THE FOILOWING IS TRUE TO THE BEST OF IrtY KNOwIEDGE: 1. I AM, pR MY COMPANY IS. RETAINEO BY THE OWNER OR THE ARCNITECT/ENGINEER Oi R£CORD TO PROVIDE SPECIAI INSPECTION fOR TF�WORK COVERED IN THlS REPORT. 2. 1 FU1VE PERFORMED THE REQUIRED JNSPECTION OURING THE TIME PER100 AS STATEO ABOVE. 3. THE WORK COVERED IN THIS REPORT IS IN CONFORMANCE TO THE APPROVEO PLANS. SPECIFICATIONS ANO APPLICABLE WORKMIINSHIP PROVISlONS OF TFVE CODE. EXCEPT AS INOIG1TEp 07HER1MSE. ��--�"<--��„�' l'�/ I.S�/ S�9nature Dats (Revised 10r21/02)