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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lr/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />/A a
<br />E
<br />Gertificate of Occu an
<br />Notes Remarks Etc
<br />FINAL
<br />O'WNI'R BUILDER DEI,(ARATION
<br />I hoeby diinn unds poalty of gcrjury rhar I m c\€nDr fiom rhc Conrict.B' Lic.trse Larv lo, rh. following reetr lsa ?011 5
<br />Busincs dd Prof6sioo Cod.): Any Cn! or Cou.ty rnich reqund a p.nnn lo .oBrtucr. 8ltd, improve. demolish o qat y
<br />sltudurc pnorb ns isumcc, also rclune rh. applicer for such p6Dn to fil€ a sisned siatoql lhal hc or she B l(osdi puuudt
<br />ro rhc pN\isio6 or rhc ConhclM s Liccnsetl LlN {Chao.r 9, Co'nf,cdins $ilh sdtion 7(xl0 of Division I ollh. Busincs ud
<br />ProaesionsCdd.)orrharlrorslEis.rmptrh@6oin.6drh.basislorthcallcged.xanplio..Anyviolalionofsd.'ltnrT0llibyany
<br />opplic. lor a p.nnit subjdbrh€ applicanrtoacivilpcnahyofnornrrcrhmfivehundrcddollflB(5500)
<br />l. s oNnn olrhe pmt yiy. or n1y employs wirh $ ar6 s rhclr $le mnD &rion, vill do lhc sork dd rh. iltudd. ii nur
<br />i 6d.d o! o,Ier.d aor elc (Sc 7014. Buins ud PorsFtrs Cod.: Th. conhddt s Li.cN Lalv do6 nol tpply to an orvns of
<br />the l,!p61y Nho brilds o! i'n!,.ve fteen, dd lvho do6 such *ort hinselr or hc6.laor rlnluglr hb or lE own €nDbye6.
<br />provided rh.t $'ch nnlroldnd s ft nor inrmdo] or ofie.n tur sl€. lf. horv.vq. lh€ buildqq or impro t@i is sld *nhin onc ,6
<br />olconplcrion. rhe O$n€r ltuild6 sill havc thc budm of pro\ins rhar hc or sh. did nor build or idpove d. pnpdy aor lhe purloe ol
<br />l. ao$ndoathcpiopdy. amerclusnrlyconr..ting *irh lic..s.d connadoE to coisrrucr rhe pmjel {s& 70,14, BNin6
<br />and Prof6sDn (ide rheconlracror's l-icc.sc t-awdo$nor aptlyro dr os n( ol pro!.nr, sho btrildsor improv6lhr€on.
<br />ond *ho.onorcrsiorsrchprojalsNitl'aConrado(9liccNdpusrantlolhe(onrrrcloasl,to*lnN)
<br />_l0ncxc'nfl u c' S(r
<br />Drle: Orne.
<br />WORKERS' CotrIPENSATION
<br />DECIABAIIO!
<br />I hd.by .rm rhdd penahy of pdju,r. of,. of$c followinS daldarioNl
<br />/, n"'" * *r, ,,",n,,,n o adi6.,t. of Co.mr ro s.lf-lNUr. for sorl.rs ompcnsarn,n, 6 prcvid€d ro. by S*rion lTOo o f rh.
<br />Ijbr Codc, lor rhe prlomdcc o I rhe trort fo, which rh. pqnit s isu€d.
<br />Ihav.andsillnaniainwort.rrcomp.N.tioni,Er.ncc,6rdtutdb,Sationl7(l0ofth€l-aborC.de.rorthcpalomsc.oa";;;au;-ad;s*
<br />^*c-JC5 W\&/8 /1
<br />l.dilythar in rh. pdroman.. oithe worr loi Nhi.hriispr'nir is issued.l sh01l.ol ehpkr
<br />$ s to b€{om€ subjcl to lhe wo!t6 .o'npqsation la$s of Calilomia. and lrN rhti il I should bc.omc s,
<br />s,o*sj comlcreln)n p,ovisn)
<br />WARNINC: l-.ilure ro sure
<br />6oiS(ltu.1700olthe I alin hwirh..'ntly $irI rho* !!o!klons
<br />No,lds .onpo3dion .ov
<br />rhou.dd dollm l$100.000
<br />I h6cby amnn und.r p.mlly ot psjury d I or liens€d
<br />ol rh. BusinN md ProlNioB Code. md my lic.nsc is
<br />p.ovision olchapr6 9 (.ondm.ins vnn sdion 70oO) ol tlivsion l
<br />,3af68// ?//9 .",,,,".,"5 ,eztOoW j-{Gxl
<br />caN aljcro.NLErDlrc.A(i[tcr
<br />I hscby a,Im und€r penally ot perjury lhal lhsc is a consro.tion l€.dinr asctrcy for rherda.nn,... olrhc sorl aor $hich this peflnil is
<br />issuc{(s( 1097.cn. c )
<br />ATII.(:ANLDICIAAAIIAN
<br />I lErby allnn unds p€oally ot pdjury one ollh€ lollorvin8 dslaral ions
<br />Dennlition Pd,nits- sb6los Norific.lion [cddal RcAularions ( l itlc 40, Pan6)
<br />-Req0ired
<br />l,eiis olNolifi cdbn
<br />Icsliryrh rhc rdic, rl rqu l,ri.ns to!:ur'is rsta()s 'uu 3l rr c or.pflicablt'tLr nris troi.cr
<br />I cdia! rld I ha!. r.ad rhis a-lreIo corply w hallCiltand(in trv
<br />iv6 olrhs Ciry and Coumyb trrd q$n rlicordinrir6 anil Srai. ti\ s r.l.rin!
<br />3h)vc nuri,r.d l)opon! In'
<br />'ns
<br />,\llpli(anl0r ,\Esnl SiEni
<br />Pem'ne Mfle (prinD:
<br />".,"l/z/te
<br />tDffil@I/-,1-/?
<br />L.nJo'" ^ddrs
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