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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 />Subfloor/VenVl nsulation <br />/ @-/Roof Sheathing rt /,t /ts ?nol7b <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif . <br />?rzotz-FINAL t/tq/t*/za- <br />Certificate of Occupancy <br />Notes, Remarks, Etc <br />OWNER BUILDf, R DELCARATTON <br />IhccbyamrnrundepqaltyoftrjurylhalIandoprlion.(onr,!c1oBLi..nsetiNrorrh.followinErcMn(Ss.7011.5 <br />Busin6s dd Prolsio. Cod.): Any Cny or Counly vhich rcqun6 a p6'ln ro codtu( thd, nnprov€, &t olish or i.P.ir any <br />srtucrurc, Drior to irs isumc., als. rcqutB lhe applical lor such Frnn lo fiI. a siSn d slar46l thal h. or sh. is liccff.d po6udn <br />ro rhc p.lvisions otrh. Co.liacltr s l-ic.ned taw {Cn0fl.r 9, Conrmcncins *nh Sciion 7000 of Division 3 otrhc ausints ed <br />PmlBiotu cod.) or fi.t he or sh. is €rcmpl ths.tom md the bsis for rh. tll.S.d .xsnption. Any viohtion oas€rion 701 L5 by any <br />applicanl lor o p6nil subjrlsrh. apllicant to acivilp.nolryol.ol 'nor.lhu fivc hundrcd dollars ($500). <br />-I, <br />6 own.r of rh. prol,lly. or my .mplo,6 rvnh was6 6 lhejr $1. .omp@.rion, will do lhe sorl dd $c $Mm is nol <br />int6d.d or olldcd fo. sle (56.'7044. Bcin6 dd PrcaeioN Code Tn ftnrracroar l,icdc L!* do6 noi @ply to a oM( 6r <br />rh.IFpdy s ho hilds oi inprcv6 rhoEn, ud $ho d{rs such \srl hims.lf or hasclf or lhrough his o' hd own .mpl.)c6 <br />provided rhal such inprc\mars e mt i od.d or oficld for elc I r. hos66. lh. toildins or i.p.ov@l ir eld silhin onc yw <br />ofompldion. rhc (\'nq AuiU6 Nill hrv. (t hrd, oaprovins rhd h. or shc did ml hrild or nn!ro!. fi. pmFty for lh. purF$ oa <br />-L <br />G oMo of rhe prcpdr, n cxclusively coorEclins { irh li.ots.d conl,acloN Io oNrrud lhe p oj.d (Sd ?044. tl6in< <br />and thliishn Codc 'rhc Contrdoir Liccm. Lsq do6 nor .pply to a o*.r o aptupeny sho hlilds or inprovs rhdon <br />end *ho conlracts lor such pmj.ds with a Contrado(, licc6ed pu6@r ro thc Codrocloas Lic€Ne La*). <br />-I <br />d cxanpl undd Salion- B. & P.C. hr tht r.en <br />Drtt: Orn€r: <br />\IORKFRS' COIITPENSA]ION <br />DECLARATION <br />I h6ebyafir lndd p€nahyotpdjury on oaih. Lllo*i.8 ddltr.lioN: <br />-l <br />ha!€ ed * ill minrain a a.nific,l. of Co6dl lo Sela-l6uc for Mrk.ro' onrp.nstion. 6 provided lor by Sdtion 1700 of th. <br />Lsbor Codc. for rhc p6lt'n@cc oarh. md lor which lh. panil is inued. <br />I havc and will mainrar wo ers corbp.nstion i.sur.nc.. s Equt€d by s<r ion 1700 of rh. t bot Code lor $. pdfom c.oi <br />the uork for unich lnts prmn is iqq.l. My wo*en co'npeGotion iNuran.c @id.nd policy numbd 6c: <br />-l.dialihar <br />in the psiormancc orlh€ Nork lor which rhis !.rmh is issucd. lsnallnol nrpl.yanypmn innnynuns <br />$ 6ro b€.o,tr subrdt 16 rh. vortd' comp.Mlion laws ol Calilomia ddasdrhd iflshould b.co'nc suhj4l ro rhe <br />\voir6 codpdsrionttuvisioroof Scdion 1700oath. kbor Codc, I <br />aployE lo oninal FEki! d <br />ion. dmas6 6 prolid.d for rfic <br />WARNINC: F.ilnrc lo suc sork6 conpddion covdir. is <br />cnil fin6 up lo onc hundrcd rhoumd dollc ( <br />Sedtun 11076 olrh.l-ab.r('odc, in-2 <br />I hocb) amnn und6 peoahyof psjury that Ch.prq 9 (commacins rirh Sdtion 7000)olDivisio!l <br />ol rhc Rutin6s ud P.olNiomCode. d nrylicmsisinfullforcc d clla{r <br />785a <br />I hcrcby aiiifln undd perlly o f pdjury thar <br />issucd (sd 109?.civ. c ). <br />lddins asscy aorlh. psaomwce olihcrvorl loi thich lhis pam ir <br />ATTIICANIDICI,ASAITO! <br />I h@ty atrnn und6 D6ahyofpqiuryo.e ofth. follo{inl! deldalios: <br />D.mohion P.mneAsbstos Nolifi.alion Fcd@l Rqularion! (Tirl.40, Pd6) <br />R.qrncd ldrr ol Nolification <br />trs66ros runovalrc nor appli.ablc t. rhir pNidl. <br />I bn is cond I aBre ro coopl, rvhtallCilyand Couory <br />aurhorizc re?rMtarir6 orlhis Cny dd counly 1o sls uIDn $e <br />,"," //-1:?\ty <br />Ext./lnt. Lath <br />5 <br />=