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BUILDING- INSPECTOR RECOHD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNI]R BUILDER DIiLCARAT'ION
<br />I hcrchy amro lodcr lcnihy r,r Frjury dar I m cxcnn fft,n thc (inrt(t,u t-icnsd lrw ror
<br />'hc
<br />lollowins cN,n (sN 7o.ll.5
<br />Bu\in!s\ ar Pi.L\\n Codc) Any Cily ot Gutrly which rcquircs a p.nnn to construd. allct. inDrov.. &'nohh or rcprn ntry.
<br />nrucrurc. prbr ro ns issuincc. aho rcqun r ihc applicrni tur\u.h JEnnn ro filca riSncd surcmnr rh3r hcor shc i( liccnscd Du.nnnr
<br />ro lhc flov'siotrs ofihc Conlricioas l-iccnscd tiw lchaplcr g. Com tncin! sith Scdion ?000 ol Divhiof .l or rhc Busirrcsr d
<br />Pmfcsions Code) or rhat lt or .hc h .xcnDr rh.r.rron drh.lxrislorrhrallcscdcrcmprn,i a.tvtrnirion.fs€rion70.ll5byan,
<br />applicd.rrorap.nnnsubj(rrhc.,itli.anrkra.irilrnalrrolnor'ft,rcrhaillv.hundrcdd.lltrrlS5u))
<br />-1.0s
<br />o*m, oirhc preIrny. or nryc,ntl,rF.\ wirh saScs is rh.n sb c.mpcnsdion. *ill do rh. trotk.rrl rhc $mhE i\ dn
<br />inrctulcd or ofi.r.d for srlc (SN 7()44. Bnsincs $d Profcsio.s Codc'l hc Contrttr s Liccne tiw d.cs norlPply tu in osicr of
<br />rhc Dmpcny wh. tuilds or inwows rh.r6o. arxl *ho d*lsu.h$o& hirnscllor hc6ell or rhrough hi\ or h$own cnrllo)ccs-
<br />providcd rhar nEh intror.rnN aE rrn inrcndcrl o.nffcrcd nrsE lf- horcki rhc huikling o. nr!$vcnrnr is eld *irhin m!w
<br />ofcom0lcrtrn. rhcONmr Bril,ld wrllhd\r lhc bndo of pmli,B ihal hc or shc did tror tnrild or inDn,vc lhc toDeny li,r rh. Puryr,$of
<br />l, "sowncr.rrhc p' ol).ny. ,n cx.hFivcly com.d ir8 wilh liccn\cd cont cknsb.onnru.i Ihc pr(+cr (Scc ?04.r. au\i c$
<br />and Rffsstu Gde: l'hc Conrrr.ror'\ l-iccnsc Lr* oc\ nor npply ro M ownc, of ProP.nt *h(, hu ilds oi nnrov.c rhcrcon.
<br />and who conrads fitr su.h polccts wnh a co m.ro(,li.cnscd lu^udr n,rh.Qrnrrcrolr Liccnsc ll*)
<br />Ir cx. ,pr undrr Sc.ri(
<br />Dale ormr:
<br />woRxERs' coMPlrnis,rTx)N
<br />I]ECIAAAIIO!
<br />I hcdhynrfir uidcr FtrakyorF.rjuryorc o! rhc tollowir8 dslarart'ns:
<br />Ihav. d w i]l ,tui'nain d (tnil({c oi consnr ro Scli:l $urc li)r *orkcrr' c.mNr\ ion. $ tmvidcdltrhys(.'rtr'ill00olrl[
<br />tf,txn Cdlc. ftn rhc pcrfomrftd ofrhc*ui( tu qiich lhclErnrir is is{&l
<br />Fnnir is issurtl My*or](.^ c,,nrrn\dion i'rsuhn.c.rtricr rrl Fni.t trtrtr$.r rc
<br />\Ju
<br />B NTJU CO r 1d+'t)\.\ lr
<br />I aaily rhii in rh. Frfoiinrncc olrhc sork Ior shich rhi\ p.rnir i\ ii\uL{. I sh3ll nor cnl,loy any !.60n in rny nrnNr
<br />so rs ro hccoflE rrhtccr to rh. \olksl .onpLn\lrtun hws of calibilin. d rSrcc lhlr il'I slx,uld b.c.ft subj.ct lorhc
<br />w.lkcr conrFnsnrion tmvhiois ofsccrion:17(Dofrhc bhr cdlc,, shrll. lonhwilh conDly wirh rh){ povtionr
<br />WARNIN(;: Frailurc ro scurc workc comFnsarn'n corcEgc i\ onhwful. ind shlll suhr.r an cnlnoFr b si ri'rl ltmlral lnd
<br />.i!il titrcs up to onc huDdrcd lfiousrnd dollns ($llx).lXx)r. i'r "ddirn,n Io lhc cosr ol conrctrern,n, drtruScs as Pnvidcd lor lhc
<br />s..ri{,' ll)76orrh.lrtnr(ixL ir..c{rtrJrrrin'f,\'\
<br />,,,,", 1 12. l:D
<br />DECIdSAUqX
<br />I hercby aflirm undcr r.n,hrorp.rjury lhal I afl liensd undcr Fovisn,n orch4rcr 9 (conrmmins eirh sc.rion 7000) ofDivision l
<br />of rhc Busitu$a Prcr.$inscodc, rnd nrt liccne is in fullfor.c and cffm'.
<br />\bcfl 4q
<br />L Vq\rb
<br />cQNrrauquaNuilllNc-d1i[Ncr
<br />I h.rhy ifllnn undcr timlly ollcrjuy rhar rhm t r.ondtucri,n lcndirg recncy Lr thc P.rfonuicc olrh. wolk ior whi.h rhi\ p.nnir n
<br />ir{r.d (Sc. 1097. Civ C )
<br />A.IILICANLDECIAEAIO!
<br />I hn$r .fiinn u Mcr t nn lry oi rcwry one of r hc t)lk,win8 dc.lt'ar rnr:
<br />D.mnlionPcrnits.AsbcstosNolificrlion Fcdcrll Rcgul' ioos{1ir1.40.P.n6)
<br />RL\tu i.d knq ol Nolificarion
<br />ffiffi;il;
<br />aholc nrnrioncd r)pcny f{r in\pcdnni
<br />s e8ardine ostEslos rcnrval rc mr lppliablc b rht tlnrj$1.
<br />ionud slsic rhnl thc atnvc irtornErio. is.omct I aSre lo coq,ly wnn all Ciry.nd Coutrly
<br />r.tescn',tivcs orlhis Cily and Counry b.trrc! u!.n rlE
<br />]\ppliconl or ig.trl SiAmlur.
<br />4') ;
<br />Q.z.l@.,
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq il/cle, ')o#
<br />lnsulation/Energy i
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Cerlil
<br />FINAL qlqltg b\,. r,&4*-l{4 /UI OO
<br />Certif icate of Occupancy I
<br />Notes, Remarks, Etc
<br />Erection Pads
<br />brrlr''. Addrs _
<br />--r------
<br />tt
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