|
BUILDING- INSPECTOR RECORD
<br />SITE.WORK ID/SIG.COMMENTS OWNl:R AUILDER DELCARATION
<br />I rrruh! arfifln undc! p.mlry of pcrjury thdt I rncknl rronr rhc Conkrct'n Lnrtr{ Lrw ior rhe r,,ll,,wina rc.$n (Scc 70ll5
<br />BL\i',css afrl Prorcssi.n Cbdc) Any Ciry or Counry which rcqon.\ I tuNr to can{rucr.llrcr, nhPouc. dcDn'lish or nPf,n y
<br />{fl.rurc, lri m irs hsudncc- rl\orrqdn s rh.lprh.mr ftrsu.h |Elrnii h lihr \iei.d sarcmnr thar hcor \h. t li..n\dl Nrso.r
<br />l.lhc polilion\ of rht c.nracrofs l-i.en*d liw (Ch,Picr 9. Conmcncin8 wilh Secrion 7fin of Divisiotr I olrh' Btrsn''* ln'l
<br />Pfl'fc\sion( Codc)or rhrt hcor\hc i\ crc'npr rh.6fmr dnd rhcharsn ior lhc rllcg.rl dxc'nPrn Anyvi.llrionolSNrion?0ll5hvlnv
<br />lprliclnr ntr aIf,rn r \ubjc.B rhc .rPlicont h acivilpcnrhyotnor 'frtrc
<br />rhrtr livc hundFd dollnr\ (55lxl)
<br />l. $ osncrofthc pnrEny-.r ny cntl,,Ft\ wrh uiScs rs lhcn qne.o'nP.n\,rion. *ill do rh. $or[ di rhc {tu1urc is nor
<br />inldncd or nflcred n, srk i SN 7L\:r. Busincs Md Eofcsbns Cod.: rh. Cont!.toi \ l-iccnsc ks do.s nor rynlv ro rn orn r ol
<br />rl[nn,Fny *h, burld\ or inprive\ rhcr.nn. anl ktx, .l,s nkh *)A hi tllorhcr*lforrhiou8hhis.rhero*ncn,rl()vcc..
<br />nrcvidc,lrhrr surh imrbrc rnremr intcndcrl oroutrt{ ntr{b ll.l!rwc\!r. rh! }rifiing or in9i(,vcrEnr,{ $kl $irhin nr }{
<br />ol coryhl inr. ltE O*rcr Build.r will lnNt rhc bodctr ol Provin3 rh!] hc or sh. dil nor build or in{,nNt th. ftulf,nv |or rtr nuqnY of
<br />-l-a\o*mrolrh.lror(ny.!ncxclusilclyco
<br />rrrin!wirhli.cn\cd.onlmckn\roconntu(rhcF'JccllScc ?(I1'1. Bu\in..{
<br />,nd Plllcssir aodc l'hc Conk ctr's Li.c.sc Law dacs not 0nnly b rnowitrofDrolcnysho htildsor inrptov.s lhcreon.
<br />and sho s Bcrl ror su.h ,,mich $ilh a Corlrct(\) liccn\cd Nrsurnt ro rhc Co rn tr'\ Li..nE bw )
<br />I rncxcnrpr undcr SL{rn)
<br />ltoRxuRs, (ttNtPtiNsaTl()N
<br />DECIA.8A:III]!
<br />I h.rrhyrffi'rundrr ,)crilryol ]Erturyomolih.tulbsi'igdc.lxrdridrt
<br />-l
<br />havc ud will tuinriin a C.d ifEatc ol Conrnr b S.lf In\u't br u$kd i .oml.nsar ion. $ ,ovidcd {q hy Sc.rio. .lr(X) ol I he
<br />htntr Codc. lor rhc p.domn.c ol ttE wod( for whicn rhc Frmir ia i*ucd
<br />lhrLcr d silltrinrai,r *orleri romnci\drnnr nNtritcc. r\ r.quircJ byS..rt l7(XrofrhclrhorCl'dc.Ltll'i-Nrlon[.cof
<br />rh- w.rk lirwhichlhis pcrmii is is\urd Nlyworkctr conrP.nqli in\trJ .t.intrr iRlErli.y tru'th.rac
<br />rpms: _
<br />-lccnily
<br />rhar in rhc p.rrormiFc tirhc work r'or whkh rhi\ r.rmir s nsucd. I \n,ll nor.f,pb! tnv Dcro! i. anv
<br />'n,nncr*, art,b..om sub(rl lolhc *ork.6 c.mr.nsarbn liwsofcolifornia- rnd rgftrhar iIl should hccom suhl.cl tolhe
<br />uorrc comp.nstrliotr pmvishns ofSc.rn,n.1700ofrlE t2bor Codc.l \hrll, fonhwirh.onTly *irh rhos [.visions
<br />WAININC hilurc ro sor. sork.s' coDwnsalion overalc i\ unlrstul. aM shall suhie.l an cnploycr lo qimirul p.Mhas und
<br />.,vil fincs up lo orc hlndrcd rhrxs.nd dollts (Slm.ooo). in lddiiion ro rhc.os olcomP.nsdn,n. dam!8cs.s Pmvidrl Inr rh'
<br />Sc\ri{r .rrt16 nirh.l ,h( C,,J.. 'nrc(q md iuNrcy \ l(\
<br />D,", t92:19 noo,,*,, AV)lllDLe cn\cillTiex
<br />ur[lrrDrr.tNrlaqEla
<br />DIICIAEAITqN
<br />I h.rby dnrhlndcr pcnahy o f p.rjuiy Ihrt I an licctrsd undei pr,lisn,n olChlrrq 9 (conmncing wirh Sccrhn 71X)0) orDivsion l
<br />ol rhc Busifts ,nd Pmfc$iorN C.dc, &d my li.cnsc is in full fore and cfltcr
<br />clo D 19912>
<br />o",". lo.).li ve,i toL Ac- NVe \
<br />CONSIRUC ION I,FNNIN(; AGENC}
<br />I hcrchy lffin! undrr pciaxyofFtu.y rhar lhcrc i\ a con{tu.rn
<br />'
<br />ktrdi13 lscfry nr rhc r.rldmun.e olrhc work lo! shich lhir pcrmir h
<br />isucn (scc 1097. Civ C )
<br />knd.ra \am
<br />-
<br />tJnJcr'\ AddE$:
<br />-
<br />APPI ICANT IIF(I ARATION
<br />I lurby i'iltnurklcr pcnrlry ol p.rjuryonc oithc folll!sins dc.hrrrn,ns
<br />Dc'nolirnrn P.nniKAsh.slos N.rifirarn,n F.dcrrl Rc[trhrtr,ns ( l irlc.lO. Prn6)
<br />R.qutcd Lcttc! oI NorirEari.n
<br />-l
<br />ceniti rh, ihc fed.ral rcsularioni Egrding a\bc(or rcmval !rc nol apflicubk r. rht PmFcr'
<br />\l.cnifr ul I h.vc Ead rhn rpplicario. and narc rhal lh. abvc inrumrion tc(rer. I rste k,.onply wnh lll Cnv,nd Coutrr,
<br />od;Nms;nd Shlc hqs Ehliis ro hilding.ohslrucliotr a,ld h.rch, &rhoi2. EPrcscnlorives ofiht Cirylnd Counrvro enl.r upon tlE
<br />abvc nrcfrn)md px,p.nt lor inspcction purFN.\
<br />c
<br />\
<br />1g
<br />c&
<br />Appli@nl or Ag.nl SIgMrure
<br />,.*,*,-",r",,, luzlnrlryro ctlACH)f
<br />ta. z-tb
<br />Forms/Steeli Holdowns
<br />Erection Pads
<br />Roof Sheathinq
<br />Shear Wall
<br />Framino
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL to-|-(B ,z)
<br />Certilicate ol Occupancy (=_-7
<br />Notes, Remarks, Etc.
<br />DATE
<br />Set Backs
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />-T
|