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BUILDING. INSPECTOR RECORD
<br />COMMENTSSITE.WORK DATE
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsulalion
<br />Shear Wall
<br />Framin
<br />lnsulation/Ene
<br />allD
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/aso n
<br />Pool Fence
<br />T-Bar
<br />ReHandica
<br />Final ReDeU rt
<br />rtEnineer Final Re
<br />Flood Zone Certif .
<br />Certif icat ol Occu anc
<br />Notes Remarks Etc.
<br />OWNERB(JII,
<br />I h.,cby rllmr nnJc! p.ndlry (, p.dury rhi I a t .\.'nlr lr.
<br />DER DEI,CARATION
<br />m rhc G)ntrnnr Li.cnsc l-aw l,t rhc lnlk,win! r.,u (Sc..7oll 5
<br />Busircs r, liorc\eon Culc): Any C y or CouDly whi.h lcqurc\ r ncmil lr) conntuct. rllcr. imtttv'. d'molish or rcnar rtrv
<br />srru.rE. pritr k) irr issu{n(c,r\orcqntrcslhcapoli.rnrn,such,cm n) fil. r \4ncd slarcmnr rh,r h.or $c s li(n*d J'nruinl
<br />r) rh. ttuvnrff of rt Conlrektr s t-iccni.tl Ij* (Ch.t'rcr D C,,mmcn( r! I h S.l|trrn 70{x, nl lrtrrnrn I rn thc Busincs 'nd
<br />Prrllson\ codc)orthd hc.r\hc L\.rcnu llrrcEonan'l rhc hJls lt{rhc allcscJ c\cn'l trrn ^n) 'trn'r''n"jar n ?orl5 bvlnv
<br />'fl. r nriI1^rn .ul''(r\tn. rffl(Jrr1,3,^'ll.nrlrvrln,i,r^^'l.rnrrchun.l'tJJrlld\t1<0u' '"
<br />l-a\owtrutrhcptuIEny,ornry.nlluyeswilhwrlcs,\rhcrqnc.omncn:dhnwl,lorhcwrn*orlrhc(ur@xnor
<br />inrcndcJ or ottar.d Lr sle (St.7o44 Busilc* an't Ptul.\sio.s Cn lc: 'l h. Conta.ktr s t-iccn\c Lw docs nor aPflv h - owncr ol
<br />rhc pDpcny w&, hius or mnr.B rrrRJn. drxl wl$ Jc\ rd k* hinrsclt or hercll or rhhush h$ or hcr own cmllovces,
<br />tn)vidcd rhar su.h inpmvcnrnrsN n.ri' cBlcJ o'.ficrcd tur eh lt, k,wcvcr' rln'h!tll!n8 o'ihF,vcnr.lN sll wirhlnonc rs
<br />;, cod{krirn. rlE Owm, Bu ld w l haE rlE htrdtn of pttvtrrt llEl lE or shc Jrl nol hu 'l .. unprut inc flslrny ft* rhc t'uq''* ol
<br />I. as o*ncr or rk ln)Iqty. am cxcloliv.l, cont.clins *ilh Ii.{n{J .onr!..loc b $.\lrucl rlE In jc.r (Se. ?l)44, Bn:ocs
<br />anJ Pnn $r,n C(ic: Ihe Cdnkicror's Ltcnsc Lrw docs n.r rl'Ply to { osbcr dl lnpcnv {h. burlds or iEprovcs rhcrcon,
<br />0tu1 who d,nrdcts ror su.h lnU.ch wdh a Cbnrncnr(9 licen*,i 0urru{nr brh. contt.ct}r s lrcnsc Lasr.
<br />_l mcr.tupl undcr S&r
<br />woRxERs' col\lf FrtsarloN
<br />I'ECL'ARATION
<br />I h.r.by {fi]m unJcr Pcnnlry of lsjury otu of rb. tulbwn'8 dcukarions:
<br />-I
<br />hrvc M,l *ill mainr$ , Ccrtitic c ol Co.s.nt lo sclf-hsure lq workc$ compcnqrk,n n Ptuvi'lc! ,'rlr bt Scction 11700 or rh'
<br />Ubor Co{b, ntr lhc pcrlbtutuc of rhc wort li{ *hih rh. P.mit is ksu.'l
<br />Ih{vcan,j*ill *int,in qo,kcF coml.n\,r bn ,nsutaroc, as ftqurcd trv Sar i(,n l7x) or thc ljhot Cr)dc lor lhe NtrolruLc ol
<br />thc work ror wh'ch rhrs pcrm is issu.rl. M, workcr' .ompcnsdi.n nsur{te fficr .nd p,icv nunh.r @:
<br />PolcyNum$c.r-Exftrcs:,/
<br />!.lucdrrythar'nrhencrr"mnrcuirhcw,trkl,rwhf,hrhtn€rn,irisissucd.Ish,llnorcrylov,lc^ohira'vm{nnd
<br />sr e! nr h.om subi*r ro rhc hlkdc u,m!.nsal ion hw\ of calilomi!. ud aa6 rhll il I should bc.om subjsr 16 I lE
<br />woikc6' Lrn{'(nsrlion prcvrn'ns of Serion l70O of rhc L.br Coilc, I \hrll. fodhuilh conPly wirh I
<br />WARNING: Fa ui. ro suurc wo c('con{rnsalo ovccs. '\ unliwtul. 2nJ shrll subjecr 'n c
<br />.ivil li'Es trp n' onc rrunlrc! rhousrnd doll,s (Sloo.UrO). in i, r& (o{ !'l (oDrrnri
<br />S..rkn J016olrh. trlrn (ixlc ll ercr rnl
<br />I hcrcby iliiltnutut.rp.n!hy ol !.riu!y rh (c.mmn.ins wi(h Sc(rbn 7(D0) orD,vBion -r
<br />oi rh. Rr\i'r'\\ l l"olt\son\Corlc my licetr{ Ll in tu[ loE &n cffd
<br />Q-lotB lo3l
<br />," ol^ ltl , 2D 20 ..",
<br />I lErchy a,ltm und.r p.ndlyolp.iury th.l I
<br />ssucJ rscc. l0ir7. Civ C.)
<br />ntr r[c Nllomrmcc ol rlE *ork Iir wlrth I his Pcrnir is
<br />trnJ.''( Nrm.'
<br />Lcn.lcr. A,i.lrc*
<br />APPLICANT DECLARAIION
<br />I hortry anim utut r pcnalr y ol p.rjury orc ol rtc nnbwDl delaal ons:
<br />Dcnnibn l'.rfr leAshcstos Noria,cr(bn Fcdc,ll R€sllarions (T lc 40, Prr6)
<br />_R.quiEd t ttcr ol Noririari.n
<br />,"0/ //'zo?a
<br />ID/SIG,
<br />Roof Sheathinq
<br />-{F|NAL 7 // lJ)* I atllUo'"",,. ol t Lt'2ozt)
<br />andCounrybcmq uFrd rh.E]f,ru,g ro builJirg .on(tucriJn.
<br />I
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