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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loo r/Ve nV ln s u lat ion
<br />Bool Sheathing 7ln tA F!,qtat'&lst---
<br />I
<br />Framing
<br />lnsulation/Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/lasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Qeputy Final Report
<br />Engineer Final Report
<br />FINAL I lla.l f4rum'lru-
<br />Certif icate of Occu pancy
<br />-cr
<br />OWNER BU!LDER DELCAR TION
<br />I hcrcdy arinn uMcr p.ndlry or p.rjuiy rh,r I d cxcorrr ti.m rhc ConrEck,^ Licc.sc llw t(tr rhc lollowins rclvr. (s.c 70ll5
<br />Busines axl Prolt$ion Codc): Atry Ciry or CDUmy whi.h rcqun \ r Fnnir i(, .o.(dcr. rltcr. inrbvc. d.,mlish or Elitr J y
<br />ntucrurc. Irrnrx, ilr i\suaMc, trlv' rcquncslhc rlrPlic!trr for su.h p.nnil ro lilc a si8red srdcnEnr lh.l h.or shc is l]cenrcd DuNurtrl
<br />ro rhc pmvhiotrr of rtr (nnkicrois Licctrscd tjw (Chrfrd 9, Coinn.mnr! sirh S.crion 70ln.f Divnion .l of rhc aurincs rnd
<br />Pot$tnr Codc) or thrl tE or shc ncxcmll thclcirormd thc$asis lor rhc lllc8cd cxcin ion ADyvioltriionolScclion?03r.5ny!try
<br />ipfli.dd ror a PtrniGobj*G rhc arnlicanr ro a ciril Fnalty ol nor mrc lnan five hundrcd dollan ($5(rO)
<br />I.a\o$tr.rorrhcp()p.ny.ornrycnurl{,}rcs*ilhwascsasrhcirslc.onlltrtrsarnnr.s,llldolhcwo*rnnlheslrulurcnn.r
<br />intnh or off..cd for slc ( SN ?{X4. Busirr\r ind Pnrc$bn\ Cod. rhc C,nnra.ntr \ l-iccn\d ltrw didr ndr amly t, ai o$tr$ of
<br />rh. nmrcn, sho builds or inDmvcs lhcto$n. lnd who d€s su.h sork hirnsclfor hc,sclfor rheuBh his or h.r own.mploycc\.
<br />pn)rid.'l rhlr luch nryn^$rms m frn i'ncfrhd d oflcrcn i(, \]k ll hos.$rr. rhc hiLing or in{'nNnrnr h s,kl *irhin one )trol.o pldnn th. Ow cr Aui cr wili havc rhc htrrd$ nI ps'vinA lhd hc or ir did s'l l,uild or inrlrcvc rhc nnDlny lor rhc purF)r ul
<br />_1. $ on nq .l rhc pmrd!. rD dclusircly.unk ri'r8wirhliccdBlco rrcirn,c. ntud rhcpnic.rrss 7or{. BuqN$
<br />d'd ADlilrirn Codc: Thc Cotrlracnr\ l-icctr\c l-!w noc\ mr aplly lo rn.rrcr oi[opcrly *ho builds or nnnrovcs rhcrcoi.
<br />,ni who .unrackr.r{uch pmlc.t wirh r Coika.k(t lic.nscd pu^on n)rh.Cotrtrctr'\ Lnh\c Uw)
<br />lr cxc r0u d$Sccri(r .ll &P('krrhnr.r{n,
<br />Dolc oBn.r:
<br />tvtlnxpni cr rtr ll.ls,r'ur nt
<br />DA;LTAtrUOI
<br />I hcrchtrfiinnu cr rmlry.l lf,rjrrtoic orrhc tul!^vinr dc(hrtrrbns:
<br />lh!v.ana*illnrainlainaCcnilicarcolConscnrloSclf.lnsurclorworkcN$n1l)cnerion.srtmvidcdforbrSecrioo]T0Ooirhc
<br />hrnr Codc. lor lnc pcrtorroncc oi rhc wort for whi.h llE p.rnrn is kncd.
<br />_l havcand will nrrtrrin workcF cohpcnsdiotr insum cc, rs rqlncd byS.rrn 1700otth. hb.r Cirdc.lor rh. pcrhnrNcol
<br />rhc sort tbr sfiich rhh ocrmir is n{cd M y wortcn co.rFn\rrion insuhncc .rftic! and Flicy N n$.r arc
<br />l'(nicy Nun$d:-Expnc{
<br />l.cniry rlrr nr rhc rcrlornrai.c orrhc $ork ior *hEh rhis t^-.rnrir h isNucn- I shrll nol cmploy ery pcson i'r any.mi&r
<br />so .s lo tKonrc suhlccr ro lhc wo*crs' conr!.nsar ion law\ of Californi( aid ,grcc rlrr if I should tf,.o'm {bj.d ro rhc
<br />wo cs' coml'cn$lion nmlisions ol Sc.rion 37(lo of rhc tjtxtr C. c. I shrll. lonhwirh cotrlply wilh rhosc J)l.vhio s
<br />TVARNINC failulc lo wurc \orkcn' compcnsarion corr,Bc k u.hwtul. ond shnll \uhjccr .n employcr ro qiminrl pcmhi\ and
<br />ro om h!!d'cl rhou\Jnd tloll ! lSilx).(x[)). tr .d(liriotr r. rhc c.j ol c.rp.r\rr.n. drnH!.\ r\ l,'o\idrd 1,n rlr
<br />Sc.rini .1076 ofrhc Iihnr Codc. inrcE(
<br />DECLA[rLI1)L
<br />undrr Inr i\nn, of Ch flrr 9i.o m,rDcing sirh Sccri(tri 7(XXrrofl)nr\(nr:lI hcrchy iiir uMcr l,cn,lrt orr.rjury r
<br />L,l rhr Bur .s r Pn't str/n\CuJc, iil r\. \ irrtrlrri,rr. trrrr.rre-s7 9/+-rfoL_
<br />,,,", E?t2-t{5Z---
<br />I hcrchy dfinn under pcnrhy oa pcrjury I o.onno.rir hNlin8 qcnry forrhcrcrhrnEncc oflhc $ort lor *hich lhh Frnril is
<br />issuci 1sc..llDr. Crv C.)
<br />AIILTCANfDEIIAEAIIO!
<br />I lrEr,y nimundq rcnalry or'I,crjr, onc.Ilhc lollowin8 de..lnr.rions:
<br />Dcmlirion Pcrnrih Ashc(os Nolili(lrion Fedcnrl RcSuhriuns (Tirl.4t). P.n6)
<br />-Rcqut
<br />d lrrcrol'Nolilic iotr
<br />'cpul
<br />( ! 'tlrdnrg r\l{(f\ r!tr1,\Jlr'. norr0|Li.nhI n, rl,] p',,rc.r
<br />Ead rhis rppli.lrnnr lnd slarcrhd rncabvc i nnnrrbn is cotrccr IrBrNlocotr{,lyrirh0llCiryrn Counry
<br />ing consrruclior md hcrcbyuurhoriz! rcprcscnlalivcs ollhis City and Counlyb cnlcr uFnr rh.
<br />c<zL-fuU-J
<br />,"*tuf (-/ !
<br />Set Backs
<br />Shear Wall
<br />Flood Zone Certil.
<br />Notes, Remarks, Etc./^l
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