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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.OWNER BUILDER DELCAI(A ION <br />I h6ehy aflim und.r p€.ahy of pdjuy lhal I d qcmfl froe lhc conrdore' Licene bw aor rh. follo{in8 ieMh (SR.7011.5 <br />Businss and Profdion Cod.): Any Cn, or colnry shi.h r.qun6 . Fmil ro oNrNd. ahE. inrprove d.lnolish or r.!qt ey <br />shdu4 p.io. ro ts isu&c.. also r.quir6 rh. applice' for soch Fmir ro 6lc a shn.d stdttut rnal h. or sh€ n lictu.d p6uel <br />to thc provtions ol$c Contractors Lic.nsed l,aw {Chaprq 9. CoDnencin! wnh Sdio. 7000 oa Dilision I ol th€ Bsin6s ud <br />Profeion Codc) oi rhal h. or shc b ex.,np fis.com ed Oe b€sb for lhc allcS.d.rdp'ion Anyviolalionofscdnrn 70115 by any <br />applica aor a Frnit subjetslhc applic"nl to acivilp.nahyofnol Dorclh fir. hund,ed doll s(S500) <br />_1, a oMs oarhc poFnr. or my .nployd *ih waSei 6 thlt $1. co,nptr.tion, vill do lh€ wo* Md lhc slrucl@ i3 @' <br />inlodql or o,I6ed aor elc (Sa.?044. Buins d Profsios Codc Th€ conftdor's Lic.e Lrw do6 nor rpply !o e ownd of <br />lh. popdy sho hilds or impr.v6 rhdon. ed who do6 srh wd hi.sc,f or hGlf or llmu3t tis or h( oM .dployB. <br />prolid.d rhar su.h iEFovffiE d. mr intad.d 6r ofiir.d tor slc. I[ howd(. rh. t ildin3 or i,nFovffir ir sld *ilhin on€ ,w <br />ofoopl.lion. thc Orrd Buildd will ha( lh. hrdd ol provins thll hc oi shc drd nol btuild or in:pb!. th. FlFly for tlE purposc of <br />_1, s oMr o f rh. Fop6rt, an .xclusilcl, contracri.s wirh licdMrl cont.cros ro coBhd lh. projel (SE 70.14. 86'B <br />and hoasbn Cod. lhe Conrr.croa! t,iccns. Lav do6 nor apply ro u ownr orpropsry who builds or inprov€s rhd6r. <br />ed who c..r6ds for such proj.ds with a contmclo(s) licfted puumr to lhc ConrDcroir Licflse L!w). <br />I on .xdpt und6 Selion- A. & P.C. for lhis r6on <br />D .r Own€r: <br />!!r8KE&i:.CQ!r8r!lAlror <br />DECI,AEA:I1O! <br />I her.by amm unda pcnaty of pajury o.. of th. aollo*ins deldarioN: <br />-l <br />har. ,xl {ill mim.in a C.nin.ar. of coGdr ro s.la-lGuie fo. workeG con,p€ns.lion, 6 providcd lor by S(l ion l?00 olrhc <br />Libor Codc, for lh. psfor:@c. ol rh. {oil lb. which rhc psiit is isu.\r. <br />I n.v. and {illm.inlain wort€rr conrp€BarioD i.strance, s rcquned byScclion 1700oflh€ IlborCodc, aor ih. palomaf,c. ol <br />rhe \rcrk lor Nhich this pmnil My sor*.B cornp.salio. insurac€ cmi€r ud rFlicy nunbd et <br />J't"-/z f.. <br />///o ftrr' E <br />_l cdrit thar in rhc psaoioa.cc ofrh. {ork lor vhich rhis !.rdn is issu.d. I sh.ll f,or mploy any psen in any nMd <br />s s lo bcome su6jet to lhc work6' comp.nsalion laws of Calilomia. od asE lhal if I should b..onc aubidr ro fi. <br />w*m' conpa$lion provisioN of S.c,lion l?00 of thc L.bor Codc I s\.11. fodh{th conply $ irh rhok p@visioN <br />WARNINCT F ilre ro s@ mtl6' compftdion .ord!e. i! u.lasful. ed sn ll subjd m qploys lo ainnd Fuhi6 Md <br />civi! nn6 up ro onc hwdr.d thoMd dolls (1100.000). i! addnior to lh. cosl ol comp.Nrio.. ddas6 6 prolid.d aor rh. <br />serion 10T6 oalh.Ijbor (trdq ima6l &d.rtomey s fs. <br />3-za-tl <br />I hrcbr alfnn undcr p.naky oa pedury lnal I m licosn u.d€r [ovision olClxpts 9 (co'nodcrns wnh seriod 7000) ofDivision 3 <br />oa rhc B,si.s ed PmfNions Codc. ed my licse is in full forcc dd €rsl <br />4n1,5 f,', s- q) 2 <br />carilaucfirdr;lDllcacllc.v <br />I ho.by arm und6 p€.ahy o f pdjury lhal th6. is a oisrudrn h.din! ogmy for the pdfommce otlhc Mrk for which rht Fnil ; <br />isucd (S(.1097, Civ. C.) <br />AISLI(ANLDECIAE{I]I}B <br />I hs.by aFim undo pnahyofldjuryonc ofrhc follo*ins dcldarioni: <br />L)€,nolilion Pdniis-Asb6los Nolificalion F€d@l R€sulalions ('l nle 40. Prn6) <br />-Rcquned <br />Lclld oi Notificalion <br />-l <br />c6l it lhd th. a.ddal rcsulatioN rcsddins 6b6los rmoval d. nol agplicablc to lhn pojdr <br />I cfiit tha I havc r6d $i! sprlicarion dd sratc ih{ fi. abov. in fomarioo is coEe.l I asre lo comply wnh all Cily and Co@ry <br />ordindc6 ed Slarc t!s. da ig to buildms coisrfldiof,, md ndsb, arrhornc r.prMrativ6 ollhis Cny ed Co@ly to drd !!on th. <br />above mcnlioned ploD€ny ror <br />.\pplictrnl or AEenr SiEntrturr 3-2i'.17 <br />a <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenVl nsulation <br />Roof Sheathing <br />Shear Wall <br />Framing 1.t %+eet 't4 I <br />lnsulation/Energy ul _\\/v* <br />Drywall v <br />^1rutr,t/< <br />.9/ <br />Ext./lnt. Lath ut! <br />Brown Coal <br />lt4asonry <br />Pool Fence <br />T-Bar 'nnlrull <br />Handicap Req t I UA <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif. <br />FINAL It ltllt.ar 4'2-r, ) <br />Gertificate of Occupancy trrs <br />Ngtes, Remarks, Etc <br />COMMENTS <br />'%tqn <br />IL <br />q -2 2'/? <br />D.r.: j-zo -tJ <br />L.nd( sAddr6 <br />- <br />I <br />I <br />Ii- <br />i---+---