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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DET-CARATION <br />I hc.eby nlirnt !nd.r Fnshy or Fijury rhar I m cxcmtr riom rhc Contncl.r' Licensc ljw ror rhc rolloNin8 tc!$n (Scc 7031 5 <br />Busin.ss Md Prorcssi.n Codc)r Any City or Colnly uhicn rcqutcs ! Frn,ir io .on{d.r, tlrcr. inl,)rcv€. dcmlish or rct3n any <br />slruclurc. rnrto its hsuarce. al$ rcqun$lhc arllicanr for such pcrmir r. nlc, siSncd st0tcmnr lhll tEorsh. i! li.cnscd puBuanr <br />ro rhc pmvhn x of rtE Conk0clols Liccn*d Law (Chlrrcr 9. Commncins *iih Sc.rbn 7000 of Divkion I ot rhc Brsincs nnd <br />Pmltssio.s Codc) or rhal h. or ihc iscredrr rhcEfrod md ih€ basi\ forrhcru.S.dcxcmplion Anyvidarionolsccri, T0ll.5byany <br />arpli.a tunlemnsohj*krhc 0pplican! ro a.ivillcMhyofnol nnnc lhan ivc hundr.d dollN(S5m). <br />-1. <br />rs ounc!ofrhc pmpcny.or nrycnDlorrcs rirn sBsc\asrh.n enc .omp.Ds.lion. willdo thc $ork lid rh {mm is frn <br />i'nc'xj.n or o'lcrcd ror slc (Sd r(}.r4. Busiftss and Pror.s\tuni Codc Th. Co rucl{t t,ico* hw do.s nor lprly ro .n owncr of <br />rhc nsocny who boildso. inrm6 rlErec 0rn who dc qch wod( hitnsclfo' hcr{lfor rhhu8h hn or hcr own cnPloyccs. <br />pflrvidcd rh such imltr.kmnh e,Dl i.tctrdcdoroftrsl lorsle lt lD&vci rlE hikli'rA or imprownEnr k hld anhin onc )tr <br />olcorytLrior rh. Oqncr Britjo will hrr rh. bon ol pnrv,ng th.t h. or she dil mr triu or irnpmk ihc ,,bFiy f.r lhc purlDc ot <br />l. Ds.wn rolrhc Jro!.ny. iDexclusivclycotrimclins with liccnscd conrrrh\ h.dniflcr Ihc proj..l lScc. ?(!-{. Bu\i]'tc <br />.nii hric$ionCodc:lhcConrracroisl-iccos.l-owdocsooramlyiornosierolProFnywhobuild\oti.,Pmhirh.rcotr. <br />rnd who cooimch aff skh ptui.rs wnh . ct)n'acb(s) li.cnscd !ur$d n)rhc(tntackn s t-iccn\c tjR) <br />I rr.t.n,t, trndrr Srcrtrl <br />D.lc: Oen€r <br />wORKI,'R'S', COMPTNS,{T()N <br />Il[cld&lroN <br />I hcr.hy,mnn und.r pcnnhyolpcrjuryotrc ofrhc iollowi.s dNlaralion\: <br />I hrlc rntwill Dinrrin nCcnnl.drcofConscm b s.lflrNtrc lnr s.rlcn ronl i\ (n.r\ pmrnhd inbyS$rn,n:l7lx)olrhc <br />l.ltxtrCo.l..n)rrhcDcrltlnDnccofrhcworknrwhi.hthcfrdir sistrcrl. <br />I h.vc.trd vill nri .in Borkcrr compcn\lrion insurrme, !s rcqtrirudhyS(rion.l7(D.irhcLatntCodc.forrhcPcrfonnrnccof <br />lhc work ibr which rhhrcrnril is is\lcd My Rorkcrs .otr1pcn\drbn in\un$.cc.iiicr ond poli.ynumnLrrr.: <br />Policy Numbcr <br />-Expircs: <br />-l <br />ccniry rh,r in rhc p$roi,runcc olrhc work n)r qhi.h rhn ocrmil is i$ucd. I \hall nor cmpk)y rtry ncFo. in an) nB.icr <br />$ .s ro m..om subjNl lo lic workcs compcnsarion la*s olCrlirornia. Md 4rcc Ih ilIshould tE om{b.l.dk,rhc <br />workcs compcNrlion pmvnions oisccrn,n:lT0Ootrhc t]hr codc. I shill. bnhwilh conrd, *iih rhot rr.visions <br />WARNINGT rrilurc ro surc trorker compcn$xnn co!.rl3c i\ rnlawtuL ,trd sh l suhj.(r n0 cnl orc, u (i irrl Fmlrics i.d <br />civil tnrcs u, lo onc hundrcd rhousad dollan ($l(l).fi$). i! addirior ro lhc.od of conrP.nsarn)n- &mC.! rs [ovidLal lor rhc <br />Scdion 3076 olrhc khor Code. i crcd dd orn.y \ rcc\ <br />UCENSELCANIXACIAA <br />DECI,AEAIION <br />I hcftbyaftnnund.i p.nallyol!.rjury lhal I trm [ensd undcr rirovhionofCh,Pru 9 (coDnrcncinB wilh Sdion TOtx]) oiDivision l <br />of rhc Busirs and Phlcsi.ns Codc. dld nry liccns i! in tull lorce iri ctaccr <br />CAIiIBIJCIIANIENDINC.ACENqI <br />I hcoby alfrm under !f,Mlty of r..jury rhar lhse is ad'nsrrucri,n knding.Bcfty forrhe pctlotmtue orrhc *urk ro. rhichlhn permil is <br />hrucd (Sc.. JO9?.Civ C ). <br />ATIIIIINLDECI.AIAIrcN <br />I rr^$y Innundcr DcnallyolErjury orc olrhc follo*inp dmbiationsl <br />D.rrclilion Pcirnits-Ashcstos Norilicarion Fcdcral Rcgubrio"s lTi(|c40. Pan6) <br />-Rcquncd <br />t.rlcrot Notifuri,. <br />lccnifyrhrrrhc lc ctul..8ultuons rcgnrdirs rshc(o\ rcnmv{l lrc nor {Ili.rhlc t,rlrir fiitcl <br />-l <br />ccniiyrhor I havc rcld rhh applicart,n ard { c rhar rhr ahvc irloirrorbn h coF(l I osre b 6nply wirh all Cily and County <br />ordinonccs lnd Strrc L.ws rbriry b buildin8 .on{tuclion, rnd hcrcbt rnrlrrnc Eprcscnhtivls oflhk ciry,ld Counrylo cnis uton ih. <br />.v. nrnrr{rd fnplny iJ in.|ccriotr ru'F\(\ <br />AppliL nl orAAcnlSiaMlure t 123l Lc, <br />D,l IPn Hi!^ <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation <br />Rool Sheathing <br />Shear Wall <br />Framino <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coal <br />It/asonry <br />Pool Fence <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certil. <br />I <br />FINAL tt74rD'I oLX) nt "tL-/Certificate of Occu anc <br />Notes, Remarks, Etc. <br />T-Bar <br />I <br />Crrir <br />- <br />knJer'( A,ldrq\ <br />- <br />tt <br />tt