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\BUILDING- INSPECTOR RECOHD \
<br />SITE.WOBK DATE ID/SIG.COMMENTS ()\\ Nltli lrull,l)laft Irl:1,( ,\R I l()\
<br />I hercn, affirn !nd$,.i yofFrjurylhtrl t am cicmpr rt,n rhc conrnctos l-i.cis tiw rorrh.n lo$inr reomn (Scc 70115
<br />Bu\n'.$ ad Proicsi.n Codc)r Any Cily or Cornry shi.h rcquncs i pcnnir lo .on{ruc|, .ltcr. nnProvc. tlcEdli\h or ftPar 0ny
<br />nrudnn. Drior lo ils isruancc, als rcquit \ rh. aDplic.ni f.rsucl ILnnii io fiLtr silncd sl.rcmnl rhat lEorlhc L\ li.cnscd lursunnt
<br />ro rhc poli\n'ns ortlE cotrra.rols Liccnsd uw (Cn!pr$ 9. Commcncin8 wirh Sccrnr. 70ln ol Divtion I oi rhc Bu\inc$ atrd
<br />Pn,rrssn,rsCodc)orlhrlhcorshciscrc'nprlh.rclioormdlhcMshlorrhcallcgcdcxcnflion. Anyviohrnnrorsc.rionT0ll 5by v
<br />arDlirul ntr ! pcdit slbjc( rhc omli.rnr lo !civilpcnllr,orn.r nx,. rhatr fivc hu rcddollml$5m)
<br />l. N owrcr oi lhe oropcnr- or my cn1llo)Ns Nirh wrrcs ts rhcn vrh cof1l,.trsrtion. will do rhc sork drd rhc sulm is nor
<br />inrcniH o, ofcrcd for slc (scc ?o1,4. Businc$ lnd li,fcsiotu C.dcr Thc Cotrtlctr'r Li.ctrsc Ii$ docs nor nlPlv ro sn nsNrof
<br />ihr lxrlEny who huilds or inIF,B rh.rsn. $d who do.s sch *olk hinNcllor hc(.lfor rlrough hh or he, owntntpkJlc.s.
<br />pn,vidcd thdr \x.h impmlcmnh uc mr inrcndcd or .flttu1 for st. ll ho*clc. rht hniklir8 or in]lt'ovsmil i\ \nd wilhir onc FU
<br />olconphlbn.lhc Owrcr Blikhr willhaw rh. bodcn ol PmvnB lh.l hc.r \hc did ior huild or nqmvc rhc pn,Il.iy ror rhc PUIIn*of
<br />L ff osncr .f rhc on,Dcny. ar cxch\ivcly .onta.rirrB wirh ltcnscd conrtrhr b .otrsfld rnc PmJc.r I Sc. 7U14. Bunre$
<br />nli PDfssir Codc: l hc conrdol s Licensc 1,!w dcs oor trpply b in owrcr of nroF y who huilds or iml( cs rh.rd r'
<br />nhd who.onri.Blhrsuchrmjcc(wirhaC.nr(d,1\)liccnscdl[suanrt,rh.C.tacrolsLiccnscL!w)
<br />lrDcxc r undc!Sccrio
<br />OPner:
<br />loBxEBrlrouUrNsAIoN
<br />DIiCIA.EAIION
<br />I hcrcby omntr undcr pcnolr, of pdjury om ol lhc rollowing delmti.ns:
<br />-l
<br />havc .nd will mrirrsin a C.nilEarc ot Con*nr ro s.lf.lnsu.c for wortcF con\tnsdio., !s lmvilcd t(, by Sdion 3?00 o I lhc
<br />Libor Codc, n lhc lcrrorm!ftc.flh. *ork for whi.h rh. Pcmir iq issued.
<br />lhrvc lnd lillmrintain workcrJ.ompcnsrli0n i uruncc.ns ruquncd hy S.clion.l?()oolrhc l-rhor Codc. lhr rhd rnnniNcoi
<br />rhc $ork lor whichrhi\I[nn is,$ucdMyBorkcrrcon,l}.nsrrnninsur.ccrrieratrdF'|i.,nurbcrtrcl
<br />Policy Nunrtci-ExPtcs
<br />-lceniiyrhar
<br />inthc pcrlonmNeoflhe lorl tor whi.hrhi\ Pcirnit is issucd l \hall.or cmplovrnvPcnon in atrynrtrret
<br />s N ro h.cotrE sul,Fcl k' lhc *ork.h .otrFns0rion lnws ot Culiiomia. md agN rhd if I \,n't lJ s..onr subicl lo rh.
<br />qor*cn ompcnslionrovhions ofs..rio,lTmoflhc Latnr Codc,I sh,u. fonhrnh comply wirh rtx)e Provhions.
<br />W RNINC, rdilum lo ccurc lolkcr compcnr in cov.taSc i! urhwl'r'|. d shsll subjccr an cmllnFr b o.tn,l ,ctrrlris and
<br />civil fin€\ u,, h onc hu.drcd rhousond doU6 (Sl(n.fixl). io addniofl io thc cosr orcomp.nsorion. darosc\ rr p.'ti'l'rl Io'
<br />'hcSNriotr 3076.rrh. bbo. cbdc. inrcresr and alrortuy r fecs.
<br />tlsEtslllcurual:raa
<br />DECIAMIIAN
<br />I hcmhyofilnnundcr pcmlryolpcrjury lhat l rm liQtrsJ undcr lrovhion ofClraprcr 9 (comnEncir8 wirh S.crion ?0OO) oft)ivisi.n 3
<br />ot rhc Busincs ,nd Piolcsrions Codc. ud my licc tu k in lull for.c 0d cllNr
<br />CONflIIlrqIrcNrENDlNlirlGEN!:I
<br />I hcrcby dltlnn u crrEnalryolperj!ryrh.rrh.rcisasnslructionlcndirrneukyrotlhctrfornEn..orrhcworllirrwhichrhhFnnkh
<br />isslcd (Sr..:1097. Civ C.l
<br />AIELLEANLIEIIABAII9X
<br />I h.rctry slldl und.r pcn0lty ofErjury onc orrhc rollowing dccl0mrions:
<br />Dcnxniion Pcmih Arb.srox Nolificatior Fcdcral R.8uhrn,n\ (Tillc 40. P0n6)
<br />_Rcqutr d h{crof Notificarion
<br />l.crfryrl rhctn.rulr+uhii()rs'cgnidtrr!rllrno\rcnnnr r. orrl)fli.rhcr)rhs|x,l.rr
<br />-l
<br />ccnifyrhar I hd. r.adrhis otit)nrridr i\comcr I lgrNrocomplyNirhrllCiryjn{lCooDly
<br />ordinrncc\ nd srrrc liwsrbrirS iurlntri7. r.prr{dkrntr ol rhi\ (iryxnd('
<br />inr,{ mnr ulf'otrdt ror
<br />'-a
<br />( at--@v!
<br />I
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />FINAL tl l)olb? -l V.<\l,,l</4 it>)
<br />Certificate of Occupancy \) \ <_./
<br />Notes Remarks Etc-
<br />C.o rl Dl
<br />Forms/Steel/Holdowns
<br />T-Bar
<br />Flood Zone Certif .
<br />I
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