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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE IDiSIG.COMMENTS OWNER IIUILDDN DEI,CARATIoN
<br />I hcEby oiltm under penahy of pcrjury rhd I rn crripr rro'n rh. L'otrlrrcro6 Li.ctrs l.o* ti)r rhc lbllowinS rcrson (Scc.70115
<br />Bu\inc$ rnd Pn,tc\sn,i Codc) Any Ciry or Counry *hich rcqunes pcnnil lo con( cr, alrLr. i'nprovc. dcnmli\h nr rcprt 3try
<br />(ru.rur.. pridb ns tsuaRc, also rcquncslhc !!plic$l fo! such pcirnilb lllt r silrEd {nrcnf,nl lh0r h€ or shc is liccn\.d pusumr
<br />ro lhc Fovhion! of ltf, Conktrcr.i'\ t-i.ciscd tiw (Chntr$ 9. Commencing wirh Secrion ?O0O of Oivisi,rn I ol lhc llu\in.ss and
<br />Pn,tuNnnr Codc)orrhrr lf,orshc ncxcmplrhcrclirm!n rhchrsislbrrhcdklcd.xctr1Pridl. Anyviol(ionolS..r[r70]l5hyrtry
<br />lDl,licadn,apcmrirsul,jec(rficamli.anrba.n,lpcaky.rnornxncrhrtrliEhundrcdtt.lh 1S5m)
<br />-1.
<br />$ .uncr ol lhc p(,Penr- or 6y cnlplotft\ wirh *ns.s a\ rhtn sh conrrtr\ilion. sill do rhc sork dd rh. {rmrc is rDr
<br />i'c8lqt.rorctudlorsald(Se7O4.l.Busirc$mdftofcsionsCoder'lhcContuctr'sLi..{LrwdocsnoriPnlrt,rn.tri$of
<br />rhcnmFny who huilds or inpn)rcsrh.d)i. { stk) dds such vnk hnnsclf or hc^.lf.r rh'ough his ot h., own cnPloycc!.
<br />ptuvidcdrh such nnl,,(nornrs cn,r inr.ndcd oroficEd for elc ll howcvcr. rhc tDildirs or imlrovefrnr is n,ltl withironc rsu
<br />olc,nglLrion. rhc O*!cr Buildd willh,vc rhurdctrorpn)linBrh nc or shc dtrl lor llill] d iqmw Lh. PR,Fny tor lh. pu{r,{ or
<br />l. rs owncr of rhc lopcny, !m cxclusivcly conra.riig wnh liccnsd .onhhB lo ..nslrucr ltE ,n*d (s{ 7(!14. Bu{ncs
<br />ml hofcssion Codc: Thc Cont&t.r's Liccnsc L.w docs nor ilplyto rrowncror[op.dywho $uilds or imlrovcs rhcrcofl.
<br />rtut who .onrr,.a n such poj.\-'ts {ilh ! Conlruchnn liccnscd flNanr h rhc d,.trochis Liccosc lr{)
<br />"d-,H*ru.*A/ 6 r?
<br />IIDI;IIIBAIION
<br />I h.rcby rrfirn undcr |fnrlry ol Dcriuryone ofrhc folloNinE dccl?Iarion\:
<br />I havc nd willnnint.in.CcnifiolcolCousenr b Sclf lnsurc rui workcn conrp(nslrior. rs rnr!id.dlirthyScctiotr:17(x)ofrhc
<br />ljtxtrCod.. r.r rh. p.rlomDrcofrhc $ort forwhichthc p€mir n tslcd
<br />-lhovcaod
<br />trillmlinranr *or*crf conP.nsdrn,n nNrr.ncc. rs rcquncd by Sccti,,n.l7flrofrh. Lah.r (i)dc, iot rhc P.rromx'icc or
<br />rhc wori &!whiclrhi\ pfn r i. ksucd My qorkctr' .onrl-ns0rion in{Encc cricr md Brli.y trutr1hcrdc
<br />-l
<br />cenilylhar ir lhc pcrformJrc Dfrhc work nn wh'.hrh^ Frmir n isucd. I shrll nor .'ntk,y ,ny Nnotr ir onynunmr
<br />{) Nh h.om shjcd t, rhc workcr\ comncns.rion hBs ntC.liri,mir. md ac(c rhd irl should bcco r ubjcd h rhc
<br />workc^ conrpc\drnin,ovisionsolScclionllT0oollhclihorCodc.lshdl.rodhsnh.on{ly*ilhlhotnr'lisnrx.
<br />WARNTNG I'ailurc ro ccure work^ conf.nrdri,nr covdrsc is uihsful. 0nd stlll q'nicr an .nph)s r. rinri'ul FTslris rn
<br />JJd I r ro rhc !n{ ,'l (rn'rcr. 'oi. d.'nu8cs r\ n,n\iJ(J tu' 'h.aA%--*-4ciril rincs un lo om hundred rhou\ud dolltr( ($l(
<br />s..rion 10760! rhc l,}rtrcdh inrcrc{ridftfrcv
<br />g- t(- tg
<br />IECLASAIION
<br />I hcrchy fllnn nMcr !.nrkyofnerlury rhlr Isnr li$ned tndc1,(,vi\nn ofChrPrs() (conrmncing snh Sc.rion?mo) oaDiririon l
<br />ol rhc Busincr\ tr0,1Prolcs$orB aodc. flIn my liccnsc is in fullbrc. imdcft..r
<br />TQNSIIjjSIIONIEXDIICTIGENIJ
<br />I hrEby trfirmuiilcr Bndry rr|)eqtrrr lh lhcrchrconsltucrioilcndire,gcn.yforrhcP.rntrmomcotrhcworkturqhichrhnPcflniril
<br />issucn (Scc 3097. Civ. C )
<br />AELICANLDECI.AMITOX
<br />I hsrt y !,lm undcr penllr, dtp.dury onc ofrhc following delaEtiotrs:
<br />Demolilion Pcirrirs-AslEsros Nolificrtioo F.dcril R.8trldio.s (Tillc 4(r. Pan6)
<br />-Reqlned
<br />kn€rof Nolir.dbn
<br />-l
<br />c.d iay fid rh. lcdcral rcE!&lioG Esading f,at*ros remval m nol 0prlicabb lo rhh IniIl.
<br />-l
<br />cenif, thar I harc rcud rh*,!pli!rio. *n alc th.t rhc abovc iofonEr ion i*.oml. I agB lo oq,ly wirh {ll Cily and Counlv
<br />con(n'crion. lrd hcrchyluihori,c rcprc*nrari ,n rhs CirJ- rkl(r tryr,,rtrrc' utfrrf,,Zh ?t6"/?
<br />tE rq tL 4t3/Zo,arl,,rt S
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Rool Sheathing
<br />Shear Wall
<br />Framinq
<br />Insu lation/Energy
<br />Drywall
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engrneer Final Report
<br />Flood Zone Certil.
<br />r\
<br />FINAL I ywtd
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc.
<br />Set Backs
<br />Subf loor/Vent/l nsulation
<br />Ext./lnt. Lath
<br />,r,r" g'
<br />Expn s:
<br />-
<br />Licns. Cl.ss: Lic.nt Num6cr:
<br />-
<br />D{.'- Contr.dor
<br />txtrJcrs Jd'cs
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<br />tt
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