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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS O\trNER BUILDER OEII'ATT TION
<br />I hdcr, 6rm u.<!.r Frlr! ot Fjurl thd I tu .toF too rh. (-.drdon Laos t$ (' rh. f.ll,o$ m3 rar (S( roi I i
<br />Itunn* dn ProGsn'n C{k} Ary C } or (ir.r! $hi.h r.lutrB . lm( lo s({ru.r. .hd, 'nFo1e &mls! or ,+. s,
<br />srrudu.. Frr to s Bue., abo r.qrr6 rh. ipplic! for such Fnd ro 61. a 3i*n.n sldmal ln l h.or sh. ! li.ft*d luRranr
<br />ro lh. provisioB ofrtE Conrr!.rois Li..nKl lr$ ((hdptd 9. (ilmmncitr8 tr'ilh S(rion 70t$ of oivhion 1 olth. h*in.s and
<br />&of6sn,ns Cod€) or rhlt h..r sh. is .rmpt lhd.6 nm drh.trsn nn Ih. dlcs.rl.rmpron An!viol ionofscdrnT(,!15 btant
<br />rt+licad aor 6 p-mn sobjds lh. .pphcanl lo r cr il pdhy o f nor mot rh.n l_r\ c hund.d &'11.6 ( 1500 )
<br />l.sotrc.frlEF,Fnt,dnlmphrGs'thq!s6silE($k..mFsa'n.rill$llEs\*tnlllrturwiN
<br />dnt d .r oirdal n, $k (Sc 704r. BoriK ud Eof6F6 C.d. I1E(nddoir LtG Ii$ &,6 @t +pl! r. otrrdor
<br />rh. I()pqiy stn toild or inFor6lhdotr lrl *hl &E sh sql h' .lf dr hdlror ihtulAh hR ot hd otrt mdrr6.
<br />r,ovid.d rhar surh mrm6rEr. erel inlsd<l ofrEtn nrr $k ll lNq6s, $. t!ildi,{ or im['o\.ffi b sH s itin on. )s
<br />.t.oq)ld6n, lh. ()*nd Builda will h!v. llE trrdo oI Forils lhd hl or rh. did ml hild or inpmv. rh. l'.pait for lhc puF)E or
<br />l. s ouF of rn FoFlr. m d.l6d, codr&1us snh li.qs.d.odndo6 ro odNd rll F.i.tr (sd,G14 &6'B
<br />.d PlotsrCo& 11. (ont,rtor3 L(.G l-.* tl.'€ mt 4ply to 6 ou.F ort oFrt,ho hildr or ihprc\d th6on
<br />&d *ho odr.d! fn.3u.h FoFs *'nh. (tnrxk(n lirrEd FlBd htlEContrtlm t l-i.@ l!$l
<br />luqdfl undr sdrhn
<br />Drr. orn.r
<br />\r oRKERS', COnl PtNSA t',ioN
<br />UECIAIAITOi
<br />I h<.b!,mm undd F,l't of lojut om oarh. (olLtr
<br />'.8 &(lda'nn5
<br />Ih.\..dsill hru t cd,frtkof coMr to s.]f.lNr. fd \dld'r.mFshn. s FtId.d ror t( sdsn :17(x) o f ih.
<br />l,t Co& toi lh. Ftotuc. of lhc *.rl for $nkh ih. Frn i! i$u.d
<br />Ihdv.and*illn.rnt.inqorl6conp.nsnln'ninsurrncc.6r.rttrtrdhrSdio.lT00oflhcl.ttErcod..for'h.Pdionuinccor
<br />rhc r o' I aor *ni.h rhn rxmit i! is.d My $orksr conpsEilion insur.n c cM ia a.d Flicy nuhhd t.:
<br />l.diaylhd in rh. Ftor.lEc oflh. uork iir shkh rhB tdmir r iqr!.J. I sh.ll n.l onploy.nt p.r$n in tr, m3nns
<br />g) s k, h<on. 3ubj(r t, th. *ort6 comFnsd ion lnws of Califom''. and axr rhd il I should h*on subjdr ro rlE
<br />*orksr c.mp6srion pmvlsioNofScclion 1?00oflh. ljtFrCod.,l JEll, lon htrilh co'nply wlh rhoe pmvisio.s
<br />W/IRNING: Fdillr. r. su€ mrld comFMhn.orG8. G u.h*ful. sd shall iutii(r dnploys lo airitrtrl Fhhi5 dd
<br />(nil 606 up ro on. hund.d ihorend d.llM {1100,000,
<br />r6rKn 1076orllE lil ftrl.- im.d tnd dt nE)'rrG
<br />in .ddnion h rh..o oa.o ion. &mlg6 &r FoYd.J fu rh.
<br />DE('I ARA ION
<br />I h.hby arfm utuld lEnihy ofpdjury rhal I anr licds.r.i trnd6 p'nvisnr or( hapl6 9 (comndci'rF $dh sarior Tour)orr)nrhn r
<br />or rh. ausihs dd I'hfdioB Codc. a nry n.o$ is in lull ror.. .,rl .lI(r
<br />(aliraiJcrlllN.LElDllli-&aDtct
<br />I h6.hr amm u.d6 Fuxy oa polu.y rha! rh6. i! a codd.lion k$ltrs esd(i- for th. FfollM(. orrh. sork aor trhi.h rhs FnIn s
<br />'su.d(s( 1097. Cir (,
<br />APPI ICANT I}E(-I ARATION
<br />I had! srmund6 p.,!l'y ofpdjuryon. olrh. foll ring d(ldariont
<br />l).rtuhion Pdf,ire^rtgror Norificalion lj.ddll R.*uhhod ( Tnk 40. P!n6)
<br />Ralln.d tAd of fdilrnFn
<br />I c6i$ rhd thc fni.r.lr+ul,rioB rctsdinr stsrG rmvil u. frn ql)lklbL to
<br />'hs t oic(
<br />l.6riIyrharIha\.rridrhi!dpplic.iion dnll!rhrr rh.atF\c inro,marnn Bcorei.I t(l,'rodr'lysirhall(irr_dnd(otrtrrr
<br />ortnndh.G md Srar.l,.*r rcl.ring to huild'ry rotrdn'crnn. arxl h-.by iurlnni/. qn6olarn 6 orrh( ( n! Md Counly lo ord ulxln rh.
<br />i,*:,- --ffi::'i*K)q,..-r "-/ 1-.---:.'.,. 4! /4 7
<br />p.mi,frr,n.(prin,,: 4tC4,+A- 6+OC A -
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framina
<br />lnsulation/Energy
<br />Drylvall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif.
<br />FINAL 5 '''(-tb -ilr{b{o fq>
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc
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