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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE COMMENTS OWNER AUILDER DEI.CARATION
<br />I hcrchy rlfirm undcr Dcnllry of p.iuly lhlr I am cic'lnr lrom rhc C{)nta.nrn Licnsc tjq lor lhe followits rca$n (Sec 7o:ll5
<br />Businc$ und Protu$n," Codc) An, Ciry or C,oil, whi.h .cqxtcs x Fnnn t,' .onnDd. rltcr. inlltrovc. dcmlhh nr EItn rny
<br />srD.rurc. prttrk, irs hsuun.c. aho rcqun r rh. rrplicDtrr ror surh pcinir ki nlc 0 siBred slalcmnr rhal heor shc h li.dntd poEua
<br />lo lhe rmlhions ol thc Conrruclols l-iccnscd llw (Chlprcr 9, Comnrnci.! wirh sc.rion ?oftr of Divkion I oi rhc Busirrc$ rnd
<br />Pi.L{snJns Codc) or rh h.or sh. k cxcnu lhc.cfmn nnd rhc bd\Ls lor rhclllcscdcxcnrprion Any vi,nribnofScdion T0ll.5 byany
<br />np,rlicdnr ior ! pcrnrir subj.ch lhc !rplicanl lo acivilDcnahyoi.ol mrcrhdi iilc hundr.ddollars (55(x).
<br />-1.
<br />$ owner of rhc |)n,tEny. (, nry cmrloye\ *irh qrsc\ us rhct q,lc .onDrn\di.tr. $ ill do rhc wort nR rnc rlnrlw is B,
<br />inrcklcd oroltcrd for qlc rse.704-1. Bnsi..$lnd ProLsions Codcr ThcCofiacrois l-iccne Lrw d..s nor npply t, osn.r.f
<br />rhc pn,IEny who huilds or inDreEs rllmn, udwhodm\schwo* hinsclforhcrclforrhroughhn orhcr o*nenPloy.cs.
<br />F,vnbd rhur su.h imrownrnh .r ml inrcndcd or oicrcd fo! $h Il horcvci rhc hikliru or nnpft,vc f,nr is sH qilhin onc )ls
<br />otconDlcrion, rhc O*ncr Buiklcr will h,vc rhc btrrdcn ornoling rhd h. or shc did nor build or impro!! rhc polf,Ily f.r rhc purr.s or
<br />L rs o*ncr ol rhc pmpcdy. ancx.lusivclr.ontadin8 eirh li.cnscd co.rracronlo conndci rh. pfl'F.r (Scc.7044. Buenc\s
<br />ad I'bfssion Codc TncContacrorsLiccns€t-s*doc\norrpplyban.!Rrornrc!. yuho build\o! inrpn,vcs rhcr.otr.
<br />nnd who $nrr.h lni su.h pmjNts wnh a A)ntucktr( s r ltcnscd I)u urDr ro lhc G).tactr's t-i..ns Ilw )
<br />;:'-,rytii 4 "",".>,
<br />I hcr.hr_ rlltn r tlcr |{n lr!of|*rjuyotrcofrhchlbtrmtdc.larnrn \
<br />lhr\r.JxlwillruinrrinaCcnificrlcofCon\cnrroSelflnsurcforworlc^drmp.ir,rion.dlnvil.dlbtbyS(lion3Tmolrhc
<br />lihor Cod.. ror rhc lf,rLnnM.c ol lhc work hr vhi.h rhc ldnil is is$cd.
<br />lhrvcrod willnridrln qrkcrr compcnslri{nr irNUrrrc.. as requncd htS.(rnr lT(x)o, rhc L$orCod.. iorlhc p.rtu'nEnctof
<br />rhc work lbrNhichlhis ncmir is isucd llysorkcs .otrrtxtr\lrn,n inrdft .c.rnicr drd B,li.y trunrbcruc:
<br />I ccdifyrhrr in rh. l,.na n&.cofrhc$orklarwhichrhis,rcnniriri\srd.Inrllnor.nlPbyrnttc*onin.nymrnncr
<br />$ ns ro lrcorft suhicct h lh. Bo*cn compcnsrr i(in h*s oI Crlilornir. und trgN rhri ir I should bcorE {h]cd ro rhc
<br />woAcrs.onqrnslnnrffuvisi,,nsoiScdioo:l7r)1)olrhclrhnCo{lc.lsh,ll.tunhw(h..nrdywilhrh--trovilbns
<br />WARNINC: FlJillrc k, {.urc Rorkc( comNns otr c.rcm8c i( trnhtrtul. an.l shlll suhjc.r n cmpl,rrtr b.ri itul Ntrrllic\ {trd
<br />b onc hu drcd rhous.trd dollors (Sl(x).(x)tr). in tudition ro rhc con ofconpctr\,rbi. drtrrtc\ rs lnvntd tur lhc
<br />sl.ritr.1076of rhc |]fttrC
<br />,rrr", t 6 lq
<br />'dc. inrcren and ruorNv s lcci
<br />llA ^,,,*",,>t-
<br />I h.rht afliihundcr lcnalryolpcrjury lhnl I !m liccnsL\l urdcr [ovision olChrpr.r 9 (commncinB wnh scctio. ?000) oiDivhion:]
<br />or rhc Bu\imssrnd Pmfc*hnsCodc. ird my li.cn\c i\ ir full l .c axl cllccr
<br />COXIiIBIJqIjI)NTENDIXIi.dGIiI.qI
<br />I hcrcby dlrtmuntlcr Fnnlly ol p1rjury thar lhc,c is !.onslruclion knd ns Dsc .y lar rhc tlcrlofln.mc olihc sort ior !hirh rhi\ Frmir i\
<br />l\\Nd tS...1097. Civ C.J
<br />AITUQTNfBEELAXAIIIJN
<br />I rrr$y nrrnuMcr trnnlty ol tErjuy orc of rlrc r'olbwin8 dslnrarions
<br />Dcnnlirion P.rmih Ashc{o\ Norin.rttr Fcd.rrl RclDl{ionr (Tnlc.10, P{n6)
<br />Rcquncd LrIcr ot Norifi carint
<br />lonilirhd rhcfcdcrdrcBulrlions rcEtuding lsheslo\ rcnn,val arc nol rlfli.rhl. ro rhir !roi.l
<br />ordifntr.c\ rtrd Srl(c Lrtr\ r]ditr! ri hu ldinl.o Nrurri,n,. rn,l lrcrchy xurlntrt. rct)ft\cNrnv.t olrhi\ (']ly Jnd
<br />4
<br />Se1 Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsu lation/E n erq y \.z\l
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/ aso n ry
<br />T-Bar
<br />Handicap Beq.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL t6/il/6 -ar67L-*?t4/
<br />Certif icate ol Occupancy \V v-/
<br />Notes, Remarks, Etc.
<br />--t
<br />ID/SIG.
<br />Forms/Steel/Holdowns
<br />,.. bt6/u/h :=+FV6Y,I
<br />Pool Fence
<br />l{'.1 ''. 4'l'I..\
<br />I
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