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BUILDING. INSPECTOR RECORD
<br />OWNI]R AUILDER DELCARATION
<br />I h.rcby lrilrn undcrycnalry ol pcrjury lh.t I m crcnrtt fronr
<br />'hc
<br />Contmclor' Liensc Lw rhr lhc iolloBin8 rca$n lscc 7(Jll 5
<br />Busin.ss dxl Pn,Icssi,ri G c): Aiy Ciry or Colnry wnicn requtcs 0 lcrn r h con{ru.r. alrcr, imrr,!c- dc,tuli{h .r ftldi aiy
<br />rrruclurc, Inior b ns nsuaDcc, rho lcquncslhc 0ppli:!trr for su.h rxnnir k,lllc d siSmd srsrc.Ent lhd tE or shc is li.cnscd punuant
<br />ro thc pmvisiotrs ofttr Conrdtor's Liccnsd tjw (Charrcr 9. Coh rminE wnh Sc.rn,. 7000 of Division I ofrtu ausin.$ lnd
<br />Pmlc$irns Code) o. th h.orshc kcrcnu rhcrcnon rnd th. hsis f.r thc,llegcncrctrrp'ion. Atryviol,iionofScclirn?011.5bylny
<br />lprlicanl lora pcmil subjcck lhc ol'Plicanl ro acjvilFnalttot.or nnnc'hrn fivc hundrcddollffi (S5UJ).
<br />L as o$ier of rhc roFny. or my cmrlores wirh slgcs a\ rhcn sh conrpcnurnrn. will do rl]f *ork ud rhc {mruc is 0or
<br />i c cn or olIcNd lor sh (S€ 7014. ausiftss and Ptuf.sn,.s G)dc: Thc Contacrolr Li.cnsc kw d.cs nor amly to {n owncr ol
<br />tlE nmtEny *lF htrikh or inlororcs rhcfr'n. and w&, &B \kh ao* hinrcllor h.^.lror rhDuEh hi\ or h.r oqn cmployc.r.
<br />l)(,vidcd rhar uch impm\rmnrs m n, inrc lcd or onircd ,or slc I I hosoq rhc hildi'rg or iqrn)vcmnr is sold wirhh onc )rr
<br />.fconDbrinr. rhcOwrc! Buiklq rill hlr lhc hu cn.l pnvir8 rh{l tE o. rhc did mr 6!itl or iflpmrc lhc pFp.ny for rh. ruFi{ ol
<br />Lrsosdrofrhcpmpcny.M,crclu\ilclrcontacringtrirhliccn\.d.otrtrcronbconntudrlEpn+.r(Se7r!l]r,Bu\i"rs
<br />!'t ltolcssion(1dc:rheConrrac,or'sLi.enscL!*rlo.smraf!lyh,.Dwtrcrotp..pc!rywho$uildsornwmvcsrhercon,
<br />rnd *ho runrr.k lin such phtc.r sirhaContndonrlice.sci pu^rrnr t.rh.Conrrcroa\ Liccn\c tje)
<br />Inmcrc rfl un&r Sccii.i .B &PC larrhisrurvrn
<br />Dnlr: O*ner:
<br />llax$;&lra!lta6a1r!]B
<br />DICLAAAIIAN
<br />I hcrcby rlltN rn cr p.nilrt .f lrrjrt otrc of r lt tull,,w i.! dc.hrarid\:
<br />I hrrc xl qill nri'nrin r Ccnilluic ol Con\ctrr k,S.lf ln\rrc lar $urkcN.! ,t)ctr\dn . ns pi.vidcd tu by Scctnnr l7ll0 ol lhc
<br />I_ txn cod.. r(tr rhc Frturmsncc ofl}[ sorL ff which ihc pcrmir i\ tsucd
<br />I hrvcnnd will fr8inr n $orkcB .onlp.nsarn,n in{rrnc.,,\ rqrirud byScdb6
<br />rhc wc ,orrnrrhthFn rm.r r\ tr{ucd Mytrorl.'!, n'{Fn!r
<br />. Ace,[,*,;r^n Ial'.^qtc Ca
<br />lTUl of rh. tjbor Codc. for th. lcni'flurcc of
<br />WLA t-[479suqz s
<br />l.cniftthDrinrhcr--rLru..cofrhr*orkntrshi.hrhhpcnniri\i\\ul{.IshrllnorcllloyrnyF.Mtrnt{nym0trDcr
<br />so asro$€om sDl,l.cr roIhcvo*cs conrpcnsarion lrw\orcalrlnrnr, rtrd.8rc lllal il l should hccom suhjcd Io'hc
<br />wo.kcn' comNnsarion pnvkio,rs of Set iotr 37m of rhc tibor aodc. I nnll. fonhwilh conrtny silh rhoc F)visions
<br />WARNINC F8iturc k, {.urc sork.6 ..mFnsrri(rt cn!.ral. i\ u hslnl. and shrll $hj.c( r. ctrflotcr ro dmnDl pcnllras a.d
<br />h onc hundrcd lhou$nd d.llars (sl(XJ.(XD), in Mdin,n ro r co{ olcompcnsl",""#;*="^*
<br />,'rppricrnr: )(
<br />DECIAAAIION
<br />I h.rb, atlird undcr Fnalryotpcrjlry rh,r I art lienBl undcr rmvision dfChanro 9 (.o'ntrftin8 wirh sdkn ?uror oiDivision 3
<br />ol rhc Busioess ann Pmfcssn,ns Codc. and m, lncn* is in full n .c ad cllccr
<br />Dst. L
<br />dIIUCANLDI.CLI.EAIION
<br />I ltaby finn uMcr ran.lty olrcrjury orc of rhc ldlosnrE d€h.ilions
<br />Dcnblirion Pcnnils-Asb.ios N.lifi.{im Fcd.ill Rc8uhrionslT lc t0, PJn6)
<br />-Rcquircd
<br />t rtcr ol Nolilharbn
<br />-l
<br />.cnir, rhar rhc LdeBl regnlrrioor reddins adEnor rcmoeal uc nor upplk"bL ro rhtu pm}{r.
<br />-I
<br />cdify fiar I h.w rcld rhis applt.rio. rln shr. rhat tlE rbow infomElion is cormr. I a8c ro €omtly wnh r[ Ciry and Counr,
<br />ordinan.cs and Sfurclflws rcldi.Bto building c.tr{rudi({. akl hcrcby iut ivcs oflhn Cilylnd Coonr, k, c rcr uF n rh.
<br />rh,v. nrnrioncd F)n.ny lor in:
<br />^rr,,.,,, ". n*"r r'*,r.* 7:
<br />u.-,',"" ,,"," , nnrr,, )<-
<br />SITE-WORK DATE IDiSIG.COMMENTS
<br />Set Backs
<br />Forms/Steeli Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />ln s u latio n/E neroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />l\4aso n ry
<br />T-Bar
<br />Handica p Req.
<br />De puty Final Report
<br />Engineer Final Report
<br />Flood Zone Certil.
<br />/
<br />FINAL tl-70-b-w.ta
<br />Certificate ot Occu pancy v \-/
<br />Notes, Remarks, Etc.
<br />j;.1t"^);2r.-,olrlc
<br />Pool Fence
<br />E
<br />)
<br />coNirauquolJ.ElpllcIcENlr
<br />I lENby afiirnr und.r IENlly of perjury lhal lhcrc k d conslruclio. tndirS a8crcy fo, thc lr.rfomuncc of lhc work ror whi.h lhis lrrmjr is
<br />issucd (Sc.. 1097. Civ. C ).
<br />tJn'1.' . NJm
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<br />I.nilr''. Jic$
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