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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS O1lNI]R BUILI,DN DELCARATION
<br />I hcrcby arfim undcr pcnllry ol Flju'y rtur I m .icmpr rx,m rhe Conk&ros Li.cn* tjw lnr rhc tblli,wi€ rcaq,n ( Srt ?0l l 5
<br />Busircss !d Prof.sion Codc): An, Ciry or Counry whi.h rc.tuircs r pcrmil lo .on(tocr. alls. imrtrov., d.nmlkh or rcirrt ntry
<br />slJu.lue. prin lo irs issur.cc. ulso rcquncs lhc applic.n 'or su.h pcrnir t' filc r sised {0i.mnr rh.t rf,or shc is liccn*d Purunl
<br />tu rlr. E.vi\idN.f rlt Contr.ror's Li.cnkd tjw (Chapr$ 9. CornmminA wirh Scclion 70(ll oI Divtnrn I ofrhr ausin.* a.d
<br />Pmfc$ions Codc) or rh hcorshc is cxcmll rhcrcliom md rhcb.sh ror lte ol!.scd crcniprn,n. AnyvnnitionofScthnr03l.5hyany
<br />aprlicanr lor !pcrmir su$jErsrhc arplica.r ro a.ivilpcnal'f.rnor ntrcrhn filc hundred dolles (S50o).
<br />-1.
<br />as owrcr of thc !r)rany. ornrycnDlorcs $il[ *ll3cs0\ lheir sikLl,hp.i\ n. will do IL work and rhc (nrrurc is ml
<br />inrcmLd.rolhr.d{rtr{lc(Sd.Tt}{.4.aurinrsandPJ'da$i,,nr(lxid'lhc(bntrcrolst,iccDsct.rwdocsnortrPFlrbrnosi.rof
<br />rhc pmFny qho builds or inproKs rhcmn, iJd *tu dm\ \tch to* him\.lfor h.^clfot rhfuugh his or hcr o*rttupk,ycc\.
<br />Ir)ridcd lhrrsu.h impnvcnEtrhm trn idcrlcd oroltbrcJ,nr $k lllhowcr.r.rlft ildirS ot mpncmnr i\ $ld *irhin one ,sr
<br />of.o {lrri,1. rlr ow cr Build.r will hiw ihc burdctr .f trcvir8 lhd hc or shc did mr huikl or impmk rhc Brpcdt td rh. Nrlr*.1
<br />l. ns o*ncr of rhc pm|xny. rflcxclusilcryconrractiDs silh liccn*dco rn.u{ h .ohdru.r rh. ln)icl (se 7Lr4.l, Bu\irrc$
<br />!ftI hbfssiD Co.lc: 1 hc Conrrtrdoar Liccns. L,w docs nor +ply k, ,n oq.cr olt'rop.ny wh{ tuilds or improvds rh.rcon.
<br />a.d who .oma.rs rur such toj.ds pnh o conrndo(9 litnsd purunr ro rhc conrr(tr s Lic.isc L,E).
<br />l aDcrcnr u.dcrSdr 0 & l'.C turrlnrcrvni
<br />IIABXEf,S:I:AMTEISAIION
<br />DESAAAII9N
<br />I hcrcby afilrnr utrds p.Mlry of pcrjury onc olrhc folloqins dalaarions:
<br />-l
<br />h0vcud*ill nDi {inaCcdiltarcol(onsctrlioSelflmurcl'oreorkcA conrrcnsari.n. .s ptuvidcd lor by Sdion .l?(xl ol rtc
<br />htxtr Codc. lor rhc pcrformnc of rhe w. for which rh. Fnnil t h\ucd
<br />)cJ lr\c r d *,ll ri' riD v.rkcr!..nr|rtr\rrion i|\urrmc, r!1,ySc.ri, .l7(xr.lrhc lihinC{)dc. tur rhc |trinanincco{
<br />N1j {rri.r arxl lrricy nu'nttir e.l
<br />-lccniiy
<br />rh(l in lhc perfo.momc oirhc No.k ro. *hth rhi\ rcrmir n is\udd.l \h.ll nol cmlloy.Ii pcr$,r in lnt 'nriirs a\ kr hc.m subj.ir o rhc *orkcs' .onl')c.sar ion l.ws of C!l,forni.. d aSerhar iIIsli,uld h.&tE bjcd torhc
<br />wor*${ d,npcnsr ion pmvisions ol sdion 37m oi thc tibor Codc. I sh!11- aod h{ir h conply wirh rhosc trovisions
<br />WARNINC: Flillre lo sccurc *orkc6 crnrpcnsarion coErlEC i\ unhwtul. aM shrll suhjsr a. cmployc, n, ainin Ftutics Md-
<br />cnil fincs uI k, one hundrcd rhoteDd Jollx^ (Sl(Xr,(Xn), in rddirion kr r ofcomncnslrioo- &ro!.\ as nn,vid.d fur rhc
<br />!}In!U].!&!
<br />orpcrjuryrh rI.mli.cNnu c.l'rovhionofChaprc'9lc.'n'mncin!wirhso.ri(r7ft)0)o,Divi\i,)n.]
<br />of rhc arsiftss.id PofcsionsCodc. old lnylicctrs is ir full foi.c {cllecl
<br />Ptw ealllitl]l-LuNrrllllllilclrN(]r
<br />t heEby sfnrm,d€r p..llryofpcrjuy lh lh.rc is. on!rucrhn lcndinS{8crc} lor lhe p€ri{}lrr1l@ ofrhcwork iorwhich$n lEmil t
<br />isslcd {Scc. 3097. Civ. C.)
<br />AITLLCANLDI.CIAtsAIIQ!
<br />I irrthy amm lodcr pcnalry.rpojxry onc orrhc rollowin! dcclaraliotrs:
<br />Dcnmlilion Pcirnih'Asbsros Notifi .arion Fcderul RcEuldionr lTirlc 40, Pd6)
<br />-Rcquncd
<br />Lclrcr oa Norifrdhn
<br />-l
<br />cenily rtur tbc tncnlEsuluri.ns Esrdn,! a\hc{os rnrvxlrrc ur amlic,blc b thh frcjNr
<br />{,.-'n,"rlluvcto l rhi! rtplic.rionmd iarclhd lhc0&,vc inrbnndi,n i\c.trer IagrNtoco ri,lywirhtrllCiryr0dCounry
<br />snrc Ldws rclntirr lo huildinecotr(rrl lu.hyrurh.rnc r.0r.\cnrrrnr\ ol {h ! Cir
<br />rbo!c trf,nrioncd !mpcny li,r in\p!rri(,n ;/#
<br />Set Backs
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsu lation
<br />Rool Sheathino l-2 c -2-*airf I o,
<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 />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certif .
<br />FINAL ,-l t -2,.o Mrl lo7
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc.
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />/, l>t
<br />,9 71o,..f2
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