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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OlVNUII BUILDIiR DEI,CARATloN
<br />I hcrchy rlfifln und$ Fnrlry ol pcrjury rhar I iflrqenllr lo'n rhc Conkrn,F l-i..ns. L.s ror 'fu followins rcr{nr (s&?0.r15
<br />Busincs affl Proic$ion Codc), Any City or Counry shth r.qunc\ r Fnnir rJ .onslruct. ihcr. i'Ill'nk, &nYnnh ,tr rlnrn rny
<br />iru.rurc, pri{nr) irs n\u,i... rl$ rLttuircs rlrc lprli.nd ror sx.hlfirnir k, filc0 sisncd srlrcn,cir rhur h.tr shc is li.cnscd Pusurnr
<br />ro lhc povisions ollh€ Conlrrclr s l,irc $d I-!w lchaprcr 9. C. mcn.irj8 sirh scdnrn 70(xr ol l)irhion I oi rl'd Bn\n'.$ and
<br />Pmit$i{nr Crtrl. ) or rhnr hcorrhc hcr.rrpl rhcEir.n,nd rhc ha.t for Ihc (ll.scnc{mprion AnyvidrrttrrorScdi T0.ll5$y3try
<br />lprlicanr for r r.in subjccrslhc applicrnr h acivilpcnrllrofn.lnElcrhrn rirc hrndicd doll \llsool
<br />-1.$
<br />ow,u ofihcl,orcny. oi ycmplolceswirhr03csnslhetn,L(xnFnirri(n.silldoth.tr.rk rlr{ururci\8,
<br />i'ncRlcJ or olltrcd lor srk lsd 7(I,14, alsin \q dnd PR,rissn,n\ C.dr: Thc Ctdh.t.i( Liccnr l-o$ docs nor rppl) t, !i otftrof
<br />rhe nmlf,ny who huikk or iNpmvc\ rhcmn. and who d*\ such rork hi'ns.ll.r h.rslror rhroulh hi( or hcr owtr c.Di,y..\.
<br />l]lovtlcd rhir su.h iDl'tuvcmnF !rc mr ilnc Ld or olicton ,ir {lc li hoMv.r. rh. h ikli$.r nnFtuv.nrnr h $ld wirhin oN ,!.r
<br />of.o,n!Ltt[ rlf Ow..r auikd sill hrrc lh. burd.. ol pnrvirg rh h. or shc did mr hui]d nr inlnn)lc rhc ln'IEny for rll rulns of
<br />L d\owJrrofrhcpropcny, r*rcxcluqrclyconrn.rirS wirh lrcn\cdco ri.t,nsn,con{rudrh.pmFcrrscc 7(!J.8untu\\
<br />!frt t\,L\\i'n C.dcr fic Conrrrtr'r l-iccn\e I rs do.s nor inrly ro 3n otrncr ofpR)l.ny \rh,) horkl\ or nnD.o\!\ rhcrcotr.
<br />d d sho onhdsfor \u.h ptujcdsqnhiConkn.bdsr li.cn.L{ purn,lnr k,rhc (inrrxd{r'\ I icrn\.|-as)
<br />Id rcrc'trDt uilcrSccron .B &P( lhrthnrrJ-a'
<br />1!aSLu!5:1l]ll-!:$r lllar
<br />t)t.t( t.\k\1t()\
<br />I hcrcby rfinn undcr lcnollyofFrjuryonc ofrh. n,lbsirr dcclamliuN:
<br />l,atxtr (i,rlc.lnr rhc lcrli,nnflu olrh. work 6r (hi.h rhc nd'rlr is l\{'c,l
<br />Ih.vc,tr sillnri ain *.ikcr{ .onrrcNrr ion iNuhtrcc. rr rqurcd hy Ssr ion .l7ll) oi lhe Litxtr Code. fu rhc Frfonrrnc. ol
<br />rh. work tu shi.hrhis Fnnir i( isserl. My wulkcd .onr|xtrsrhotr iNur f,c.rrirrindE,licynunrhcrr.
<br />I .cnify rhrr h rhc p.rfonurc .f rhc Eork tu Bhi.h r hi\ lf,nnir n hnrcrl.I $r1l.or cnpn,yrny F6on i'r rnyhr ct
<br />s N ro lEconE subF
<br />'o '
<br />hc $.r kcrs' conwnsir ion laws or ColiforniL d+Bih irI \hould h..onf, \uhj..r t' rl'.
<br />uorkcF' conrFns.l ion povtions ol scdn,n :17(x) ol rhc I nhn Codc. I \h l. r{,nhqnh .. rly wirh rl${ Frvi(iotrs
<br />WARNIN(;: tiilurc ro {cud workcK conprtr\dn,n.ovttuEc ir urhstul. aftl shall su6Fd , cnrl,rtcr r..ri'ni'irlltirlrat nnd
<br />civil ,lnc\ np ro onc hn.nrd thous!trd dollnrs (Sl(t,.000), ir lddiliotr b rhr.od orro rp. \rrnnr. dr rgcs N Prornlcd lor rhc
<br />Scctnnr 1076 ol'thc Labor ('o!c. inrcrcn n nrtontyi le\
<br />Derrr Appliconr:
<br />r r(rlsrrx:tx,rmt:r0n
<br />DICI.AAAIIA!
<br />I hcrcbydnir nndr r.nalryol!.rjury rhd I.,n liccnicd undd lmvkirtr ofChipt( 9lcotnnrn.inr wirh S<rirn 7000 ofDivnion l
<br />ol rnc Blsincss !.n Pofcs\ionr Codc. nl .r, licn\c ir in fnll fom dld clltcl
<br />raNErnlJlrll)lrl;lDlNclli[N1:r
<br />nsucn (Scc.lrn?. Ci!. C.)
<br />Lcftlcfs Nrnrc:
<br />-
<br />t ndcfs Addrcss
<br />-
<br />AIIUIiIiLIIE!:LIrAAIION
<br />I hctrty fiirnundcr pctrrlry ofpc'jury otrc ofrhc n)llowitrg dtclararbn\
<br />Dcnmliri, Icrnrir*Astlios Norilicrrim ltdc(lR.sulirnr\ ('l irlc ll|, Prna,
<br />-R.quircd
<br />t.cu.r.l NorirLrri,nl
<br />l..nifyrhd rh tcddrdl i.tsrl&rnN rc8.rdi.! rstc{ s rcnr,vrl irc .or rDnlic$lc b rhi\ px,jccr
<br />l.cnilrrhtIhlvear lhhupplicorionandnrlcl[ rhcnhrvc inlbn, nr i"corc.r Irllak,.unrrlysirh3llCir]x.,1(i)onry
<br />ordimnccs md shtrc LrNs rcl iDsrohuildin-qcon\trucrn'n.ondhcrctryanrhori,rfttrc\ctrrarilc\ulrhnCny d Counl] ro cnrcr unon lhc
<br />nborc mnriorcd pmNny {or in\pcdt,nrur,oss
<br />Applicnnr o. /1B.nr Si!tr{turc o
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Roof Shealhinq
<br />Shear Wall
<br />Framrng
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />ltilasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Beport
<br />Flood Zone Certif .
<br />FINAL A'5- /6 ,J).5"*z c9
<br />Certiticate of Occupancy
<br />Notes, Remarks, Etc.
<br />Set Backs
<br />Sublloor/Vent/l nsulation
<br />Brown Coat
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