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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNT]R BUILDI'R DELCAIIATION
<br />I hdeby .mnD undd toalty of pdjury rhat I an .&npr frrh rhe (onkrctors Lic.ns. Lds aor rh. followin! r@n {5(.7011.5
<br />lausitrBs and Prot6sion Con.) Any City or Coubry which rdtun6 a pnnir ro consrrud. ah6, nrproe.. ds.olish or qEtr dy
<br />r.1@. Ihdr to ns nsuecc. also rquirB rh€ applicol lor soch pennir ro frlc a sisncd sraroot rh, h. or sh. h li.6.d p6udr
<br />to lhe provisioG ol the Conrr.cloas l-Eeis.d Law (Ch.p'd 9. ( om,ncncins wilh Sation 7Oo0 of Division I ollhc Busins dd
<br />Por.str B Code) or lhal h€ ors& 6 crenpr lhschom md rh€ basis lor rhe allelcd crmprion Any violalion oasdio.70.1Ls b,..t
<br />applicant ior.pcnnn subj{8rh. applicanr to a.ivilpcnahyolnor mor€ rhe liv. hu.&ed dollas ($500).
<br />M.-.*,-"r*.0--r.ormyrnplo)6q h tr a!6 s rhctr sr€ composnoo. srll do rh€ \ort d\l th. lrnduc is nol
<br />-,f8a"t -"n "t rn.*r.r(- roir. a*i;o. *,1Ptor;io* cod.: rh.c;nrlciois Li..G bw d.6 nor applyro oosqor
<br />the ltrop€ny trl() hoil& or inproveIhseE e who dos such trll{ hnro€lf or t6.llor thmush his or hd oM cmployc,
<br />provid.d rh.t su.h mEovdndad.tul i,noxLd onq€d lorslc.l[ horv6s.lh€ h,ildilB or i'nprevonot is sld Nilhin on. )@
<br />oaconpLrio,l' lh. Or$s Build6 sill havc lhc t!.ds olDrcvinB lhd hc or d'e did nol trild o! imprev€ thc pNpsly lor the p!ryDE of
<br />-I.
<br />6 osns olrhc pmpdly. d exclusively c.nlractin! wirh licms.d conrradoE ro .onnrucr th. lmld (sd 7044. Ddins
<br />d ftlllsioncodc: Thc Co n.lor's Liccns. Law do6 60r applyto an o{nd oi proFny \rho buildso! inrprov6lhrsn.
<br />and sho co ads for such Foj.ds rnr a Conr6do(, licos.d puGu rlorh.con aclofs Li.m* ti*)
<br />I in,rlcnu lnder Sslui-. B. & l'( i,rihisrcarnr
<br />,,,," - l(. zc:-1cQ o*,"., X- w,LqftM. 5r\
<br />t!oalEarl!!!Erl-Ir-u0.r!!!rz!34!!a!
<br />I hcdbyrllt trndcr pcnalryol p.rlury .nc ol rhc loll vLns d(l rrors
<br />_l hav..nd *ill,nai.rai,. Cdin.ar.ofCo6nr ro Scla l6ure lu qolkgl .onrpdreliotr, d Fovid.d aor by Scction 3700 ofth.
<br />L.bor Code. ror lh. pclomsce o f the wort fo. \ hich lhe paril 6 isu€d.
<br />I hav. and will maimain solt.ii' conp.Nalion iEurance, 6 rcquned b, Set ion 1700 oilh. L,bor Codc. for lhc pgfomdcc ol
<br />Ih. {orl for vhich $is p.f,nil t ised My qorkeR c.q)@iio, i6!re.. cdi6 md polic, f,unrbd dc:
<br />.mier
<br />Policy N!mb.r:_Erpird:il/?l{/.or,tr rt,r
<br />'n
<br />rt. p..ro..an(. otrhc rorl tnr trh'ch lhis pomil is issued- I shallnor €mploy any Ptcon in dy nannd/ clsr.beon. brdr h rh. rorl6 $'npss
<br />'on
<br />la*s olcrlifomia, &d agre lh.r il I should b{omc subjat ro Ih€
<br />workdl compcnMlion provisioB oaseiion I700 or lhc bbor cod., I shall. tonhNilh co plys'ilhthosprovisions
<br />WARNING: Failurc ro s(uc rvorkm' oomF6alion cornse n unhwrll ed shau strbjdl mployd ro sininAl r(Ehirs ed
<br />civil line up to o.. hud&d rhous&d doll6 (S100,00{)). in addnion lo rh€ .osr olcohpecrrion. d0m8s 6 p,orid.d Io, thc
<br />Sd1'or .1076.1 I'c I dhnr Cod.. n'fld J dtui.l t ls.
<br />o,,.. - 111-c,2cre D( ,vrLrrAr!^- 1ny trXlrffi
<br />ITICI.AEAIION
<br />I h€rctry amrn u.dcr peElty o I pgjury that I on lics*d undd provision olchapls I (cotund.ins *irh Sdlnn 7000) ofDivision l
<br />of rh. ausins ,td Prolsio.s Co.le. ad nrylicmc is in lull lorccmdeilEr
<br />LicdscNumbq:
<br />CO.NIIAUCruNI,IBITIGIGI'ICI
<br />I hercby ,flim u.dd loElry o t perjury that rh6. is ! connruclion hding lsdcy aor $. pdfoflMc. of rbc work for which lfiis p6mil G
<br />issu.d(Ss. 1097. Civ. C.).
<br />AIITTANLDICTABAIIA!
<br />I h6$y afinn trnd€r p€nalty olp.rjury one ofrhc follo\uins d(lualions
<br />Dcmlilion Psnrirs-Asbrsros Nolifi calion lj.d6al RcruLtions (Tnh 40. Pan6)
<br />-Reqrircd
<br />Lclle ol Nolifi calnnl
<br />6&sk's ron lal arc n.r appli.abl€ to rhl! projd.
<br />thar th. rbove i.ao mtion is corar. I ssre to cooply u ilh .ll Ci'y and Counr,
<br />$ ofrh$CirInDd(inn ) t, cnrn uBr rh.
<br />ah^r\e Drnlioned p'ntcny f.r ins!(li.n
<br />Applic{trr 0r.1gcnl SiEnrfire:",,,"1i'Zo k''L
<br />x_arv\ aE+4
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />foof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />H andicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL ?{>/l t //a{oYf-?z-)
<br />Certificate of Occu pancy
<br />Notes, Remarks, Etc
<br />-+
<br />Subfloor/VenVl nsulation
<br />I
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