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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNFJR BUtI,DER DELCAR{ION
<br />I hc.eby arllrnr uoder Fnalrt {,r p.rj!ry rh,r I rn cr. rrr lmm rhc C.nteron t.iccne liw Ior rhc at,llowin! rc.vrn ls.c.7oll5
<br />Ilu\i.cs\ and Protc\\bn (-''xlc) Atry Cny or Counrt {ni.h r.quircs r rErmir lo con(dcr, rlrci in/ovc(dcmlist oFnlln my
<br />srru.rutu, prior ro \ nsuancc. aho rcquncs lhc al1Plicanr ior nrchlcn.ir x, filc !siSncd idc,mm lhar hcorshe n lien\cd ptr$lnr
<br />ro rhc provhn,ns ol'rhc Conkacrois Liccnscd hw (Ch,fl.r 9. comncrcinS wilh Sccrion 7Ltx) of Divktu..] oI rhc Busincs rtrd
<br />Porcsiun{Cod.)orrh,r h.o. sh. tcrcnU lhcrcliomond thc bnsis l'or rhc sllcacd crcnDrion A.yviol.rionofScclionT0.ll.5hyrnt
<br />nttlicaN for a prnnr subj(ls rhe lpplicur b acieilpcmlryolnor.rerhai nvc hundrcd dollals ( $5(x)).
<br />I. r\ .wmr .r r h. pmpcny. or my cmployccs sirh *oscs as lncn $b co'rycn\d nr will do rtr *rk .d lhc slur@ ir .or
<br />inrcndcd or orilr.d for elc ( Sa.7044- Busincs ,nd Pmfc\sn,ns Codc Th. Contrrois Liccns La* docs nol lprly b ,n owrr ol
<br />rhcrmF-ny who hoildsor in{ft,Es rtEEr. sxi who des sKh wu* h,msclfor hcr{lfor rhmugh hh or hs own cmPl.yccs.
<br />provntcnrhrr skh i'nln,k rdrsdn mrii cndcd nr ltcBi td srh.ll howcvcr.rhcbuiHingor iq)rovcmnt kvrtlsirhinl,ft )tr
<br />.f con!,lcrion. rhe Ovncr Brildcr sill Mh rlr bxiLkn of pn,vin! rhnr h. or shc dil nor huiu or nnpmre rh. F,FYry for rhc purfne ol
<br />-l-
<br />rsoqncrolrhc nroF.ny. rneiclusivclyc.nrr&ri.s*irh liceh{d . o trhdcktrs ro co nsl rucl lhc priccr isc. TO44, Bu{trcs
<br />and t\.fcsi,i Codc: Th. C.ntictr\ LiccnscLnwdocs tror {t!lyto an.$ncr ol F,p.nywho buildsor irprovcs lhcrcon.
<br />ind who o ncN io! such rrojcdr *nh r C.nrnct,i, ltun\.d pur\Mnr ro rhc Coffrlol( l-iccnr lj*i
<br />I MrcxcnrDr urlcrScunnr-. a & PC rorrhl( rcrson.
<br />D,lcr O*n.r
<br />ll.t8trnILt-CAIU[IIl rAN
<br />DF(:I ,\R,{1'ION
<br />I hrr.hy {finn undrr p.trdlryofpcrjuryom olthc lollowins dcclar.rions
<br />I hrvc Md will nDinr.in , (tniacdc of C.n*nr ro Sell lnsurc lor eorkcrr' c. nrr. nsdr ion. N B)vidcd ntr bySccrt,n.lT( otrhc
<br />Utxtr Cod..lor rhc pnformmc ofrlrc uork lbr which lhc Fnnir is hsucd
<br />I hav€ rnil willnuinrrii *orkcr{ conrpcnsorion insuramc. rs rcquircdhrS..rn,n.l?(x)ofrhcLrborCodc.lbrrh.Il.rrormtucot
<br />rhc work lorshi.h rhis l)c nir is issucd MyworlcF comlcns0rion itrsurancc cdricr r Plicyflumbcr orc
<br />F.t
<br />I{.u.'
<br />\L e t\9
<br />*.*. --l cqqq0J tLltll {
<br />-l
<br />ccdiryrhnr inrh.r.r{ninDmcoflhc wort lor shichlhis |f,irnil is isuql- I \h,ll nol cq}loy any,tcnon inlnynutur
<br />s r\ k, b.&m sxba.r h lhc $ois( compcnqri'n hws .f Crliforni,, .nd !8ec rh{r if I should hccom sul,imr rd rt*
<br />workcs conr.ns,riofl p$visionr.lScc'ion ]TOOolrhs l-it rG,L.l shll. fonhsith comply *irh rhoc pbrisi.ns.
<br />IVARNINC hilrc ro suc vork rr cornFns.rion covcrDsc is unhwtuL ,nd shrll \ubfrr M cnr!!o)$ h ainrinal tculric\ dnd
<br />civil fircs ur b ore hundrcd rhou\and dollrs ( 100.{xxr). ir oddirion lo rhc coir orcompc.\arion. danqcs as nlolidcd fu rhc
<br />Sccl ior 3076 ot rhc Lllu C.dc. i.r$.sr ,nd .tui,ry s rccs
<br />\"^,.,5/751)$ noou*,, B.rqat4lJazqucz' LILENSEIT d)NTRACTaIR
<br />DECIdSAIIO!
<br />I hctohr iflnundd l,cMlryofpcrjury lhor I u'n liccnscd under polnion orChrt)ln 9 (ofrncncins wirh Scclion 70(x)) orDiv,\iotr 3
<br />oi rhc Btrsinesrnd Prorisrt,ns cod., $d trry lkcnsc is in full lnre lnd cl l'cc'
<br />K
<br />n ;Ca,.,'"".,.,". L-, l qv.gLlT
<br />,"512>lrir Ce aw+a \
<br />calsrBiJcuoxLDN.DlNclc.ENLr
<br />I rf,eh!afi nuMcrpcnrllyol,'erjurrrharrhcr.nrcondfl.ri lcndirg rlcrcr lor lhc pcrio.mtrme otrh. wnrk ror qhirh lhis Pcrmil is
<br />hsu.Jrs( 3097.Civ C )
<br />AIPLICANLI]E(IA&II!]N
<br />llnhyafiimlndcr prnshy orp.rjury otrc ollhc followinB dNhrationr:
<br />thnmlirnm Pcrnrih AstEnos Norificdio. F.dfrl R.EuLr tinl (Tirlc 40. tun6l
<br />-RcquiBl
<br />lr(cr of Norifi.ation
<br />I ccdilirhrr rlr lcdcrrlrr8uhri(nF rgadi'r3 r\h.(.\ rc nrrlrrcDotrfl,lcrhLr,ihisnn'Jccr
<br />-lccnirrrhrrIhrvceadrhis{plic,rionudn.thdth.lhiqinfuruii{inircom.r.LSretoco.r
<br />y wnh all Ciryand a,xnry
<br />ordimncc\ ud srarc lj*s rclurinS to buildin[ construclion. a.d hcrchy rurhori,c topdcnrdn$ r'llhn Ciry md G,! y'o cnr$ ul.tr rh.
<br />ffi::,-^.:il::'",rtu4/
<br />!"-'**'"''n'"' VxYaa Vz4-<7
<br />,",.,q tT/lgr
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsulation vlW
<br />Roof Sheathinq ;-?-11v .1SrPffi,| ,t{'9' /
<br />Shear Wall Yr'
<br />Framinq
<br />lnsu latio n/E ne rqy
<br />Drywall
<br />Brown Coal
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Depuly Final Beport
<br />Enoineer Final Report
<br />Flood Zone Certif .
<br />FINAL b4- t8 Jlc,foit '(-vt )
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc
<br />Set Backs
<br />Ext./lnt. Lath
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