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SITE.WORK DATE ID/SIG.COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/VenUl nsu lation <br />Roof Sheathing <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Jtlasonry l -frJ <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report ) <br />Engineer Final Report rL \l <br />Flood Zone Certif <br />1u- <br />7 a-ztz)ll <br />F!NAL ffir fZ ti SNttln <br />Notes, Remarks Etc <br />Certificate of <br />"l-, <br />O <br />.--> <br />BUILDING. INSPECTOR RECORD <br />0WNER B(JII,I)ER I)IiI,('ARA'I'ION <br />.pplicant for a pernlit subjects the applicanl to a cir il penoltt ofnot rnorclhan fire humlcd dollars ($500) <br />_ l. as os ner oflhc profErly. or my enrpl()yes rvith rvages as theil sole conEnsalirrn. rrill tio the rrork anrl thc slilr(turc is nol <br />intcnded orollered forsle(Sa.704.1. ll[sinssand Profesirrrs(ixle: lhe(i)Dlrnclor's l.iccnsc l.as dosnot applltoano*'nrof <br />thcpoFnly \vhobuildsoriipro(elhs'qrn.andshodossuchso'khinrselforhcrselforthnrughhisttherornenrplolccs. <br />mlc). <br />ancl rvho conlractsforsuchprojcctsrvillra(()rilracknls)li(rnsedpulslrailllolhe(irntrilctor'sl-icslsel.a\). <br />I an crcnrpl under S(tion . A. & P.C. for this reason. <br />Dfller ONner: <br />w()RK1:RS' C()l\lI't:NSA',t tON <br />I)IiCLAlt,\l ION <br />lhcrebyafliununrlcrpcnaltyofpcrjuryoncoflhcfolklvittgclcclaralirrns: <br />I havc ard *,ill nraintain a ('enificale ofConssrl m Sclf-lDsure for \rorkqs' conrFilsalion. as pror itle<l for hr Section 1700 ofthe <br />t,abor Code. for the po fonlancc of the rvork ftrr rvhich the pernrit is issued. <br />Ihaveandrvillmainlain*orkers contJtnsationinsurance.as rquiredbySeclion.lT(Xloflhel-abor(odc.ft)rlhcpofinmmceof <br />thc rvork for rvhich this pennit is isued. My rvorkos compcnsalion insurflnce cario arrl grlicl'rtrrher are: <br />crurier: \EX!€44?f <br />Polic) Nunrbtr: - - l:rpircs: - <br />so as h lrconlc suhic(t b lhc lrorks's'ronlpensalion lass ol ( nliforria. and fltrcc lhal iil shorrltl lxconrc srrhiccl lo lhc <br />ciril fines up to onc hundrcd lhousand dollars ($100.0U)). in addilioil to llrc cosl of rlarnngcs os pror irled for the <br />Scclion 107(,ol tlrc I rlrr (ixlc. irtcrg?-zu-ra irn(l alk)r ilcv s li'cs. <br />I lrcrcbr alfir nr unclcr ltnaht_ oflrcr'iur r lhal I ailr liccilscd urklcr ( lripls Q(cr)ilrneilcin! $ith Sccttrtr 70{)(l) r't l)ivision -1 <br />oI the l]usirrss and l'rcfssions Codc, ancl nry liccnsc is ir lirll forcc anrl effcct. <br />l,iccnse (I <br />? <br />,- <br />.-A 6Z-tc t rrrrrsclnrn{v: ' 7q //D 9' <br />(oil,rnc,or ) 7-)-V4/z-lhler I <br />CONS'IRUC'IION I,IiNDINC A(;IiN('I' <br />issued (St'c. .1097. ( i\ (.). <br />Lcnder's Nnme: <br />l.cntler's Arldrcss: <br />APPLICAN'I' DECLARA'TION <br />I lneby aflinn rnder penally of perjury onc of lhc firllos irrg dalarations: <br />DenrQlition Permits-Asbeslos Notificalion lrcderal lleuulati()ns ('f itle 40. Pa116) <br />Required l-ctlcr of Nolifi cathn <br />I cdlifv lhal tllc ll(leral rcgulalioils rc8ar(li0!. ilshslos rflrxrval nrc nol nl)pli(al)le lo lhis llroiccl <br />\)unl\ to riltq uflnr lhe <br />?-ze 16lhlc 'l;ffi ;-:;;'l"",^'"*;"""'ff )*?/..-&4 <br />Perorireen{nrc(prinr):x 74rrn'q .4Ct E, <br />,.Y rA <br />,'u <br />Attr <br />9Z' <br />\{'