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BUILDING. INSPECTOR RECOBD
<br />SITE.WORK DATE OWNF]R BUII-t}ER DEI-CARAT(}N
<br />I hcrcby rrftnr undcr Fulrr l,l Frjury rhdr I m .\.npr ft, rhc CorkNnE Li.cns tjw ltr rhc Lll,,*inp rcdr)n (scc.70:11.5
<br />Bunnc\s E:rl Phfc{ n Cdc): Any Cdy.r C.unry whrh rcqutrcr ! pcrmir b .on{ocr. ,lrcr. ihPtuvc. dcmol$h or rpan .ny
<br />nn(xrc,ontrto rls issuancc,,h. rcqurcs rh! applicrnr ktr \u.l, Frm t,lllcx sllnLr, darcmtrl rhar hcor it rs h.h{d nu^u,
<br />kr rhr fovrn'nr .f rlE G)nlri.(tr s Liccrsc! li* (Chrtt.r 9. Conrhcn in! wnh ScctNn 7(Xx) oi Divnbn .1 ol rhc Bostr,c\s dd
<br />Pnni$rnr Co,lc)orrhrrlr orshc i\ crcnpl rhcrclinn drl rh. hrst ldlhc allcled crcopr i{,n Any vn'brn,n olSccrn}67011.5 [y.ny
<br />rmhcatrr fd a nfifrn suhjcch rhc .pplicml ro a civn fn.lly rl nor nuc thrn filc hunJFl dollds (S50O)
<br />-L
<br />rs owmr olrhe pbt dy. or my c,npnrF{\ wnh *i!c(.s th.ir e,lc rompcnsnn,n. will d. rh. w.rk ail rhc nurE i\ nor
<br />nlctrdcd oiol] rcd li,rslc (S.u 7044 8trucs and Prunso.\ C'rrl.: 1hc Cir n.!trsl-'ccnschwdocsnorrrPlyk'rnnwncrol
<br />rh. pn)tHy qln) tdildso! mpn)rr t,rB)n. Jrl who 'nx\ \uch k,rk h'm\.U or hcnclror rlF,uth his or h.' own.hPklyes.
<br />!n,vd.J rhrr skh impn,v.ftnk m n)l i,rtc cd r oll.E\i lar qh. ll. h'*cvcr. rh. h{ildinB or r{'ovcmnt is sol] *nni, onc ,!t
<br />ofcomlbln,n,lk( owncr Buildcr willharc lh. turJcn ot pn,v& rhll h. or dr did nol ltrriltl or inPnvc thc lm|'.q ritr rtu lu{x,{ or
<br />L !s.wncrol rhc p!)pcny. rm.rcirsivclyconracrif,g wih hccnscJ..nhrtn\ b dlsrru.r rlrc pn,j.( (Scc. ?0,1-4, Busncs\
<br />?Rl Pn sr(rr A)Jcr Thc Conk!.ktr\ l-i.cnsc l,aw d.cs lor apnly t, rn owncr ot F,!cd y !h() hullds or rmlovc\ rhcron,
<br />r stu.onkaGnr\&hr(,iccBUirhaContdco(tlNnscdNrudnrt'rltr(()ntrttr'\L'c.n\.Lxw).
<br />_l adci.n u.'l.r S.crio
<br />laacESElgLlEENl rO!
<br />DEclAAAIIOts
<br />I hd.by afltn un'l$ r. rlry or p.rjury onc oI llrc tullownc Jehralions:
<br />-l
<br />hav. :nd will mirr.h . Ccrliti.alc of Consnl ro Sclllnsurc ,nr knkds onP.nstion. .s ,mvidc'l lor by S€crion lI)0 dr lh.
<br />tllnr Coti., fdr rhc lr.nbl:,Mc. of th. mlk tor wnEh lhc lem is nsftd.
<br />4l h.rc ann -iU B.inrrin *"rkcr' coqhiar ion msurukq ri rcquiFJ hy sd bn :r?00 o, rh. trbor oi ic. ri, rh. FrfomN ot
<br />rh. work nlr whi.h this ncm,ir i\M, workcn' q)n[.nsrli, insur.ncc sricr ad fnicy num$.r dc
<br />/;
<br />U t,t 4-z-7.,
<br />_lcc rly rhxr ir rhc pcnonnrNc oI rlE work li,r whrch rhrl l].rm t i\\u.J.I dull nor.m!l')ylny |ErsD hrnynunmr
<br />$ N b tE()N uhj.ll 6 thc wortr\' cont nslri,n lrw\ of Cal'f(rnn, d {!R rhar itI \h'uld hcconr\uhlc.rro l}E
<br />workcri comr.n\arion F,virris of Seton I7fi) .l thc tjti)r (irlc. I sh.ll. li,n h*irh connly wnh rlre F)visnns
<br />WARNINC: Fadurc l,) ccurc *orkcri com!.n\ari('n.r'vcrrsc i\ u hwtul, $J shrll suhj&r M cmnli)yq b crin,innl n n,h$ ind
<br />civil lincs uO lo onc hu rcd lhous J dollirs (Sloo,llt). in rJJ rn h rlr ro{ f cor0cnsari,)n, 'hma8c! as nov dl ld rhc
<br />sccron 1076ol rhc bhtrOilc. inrcrn an,j a orm! s
<br />),
<br />DECI {RATION
<br />I hcrbyalt0'm und.r p.nrllyofFrjury lhal I am lienqj uder pmlnio. urchapr.r 9(uommncins wilh SNli,n xll orDNision l
<br />of thc ausftrs ahd Po,cssions Cclc, .ll my liccnsc is in iirll li&r dn ctftcr
<br />X-,-*".r,,,3
<br />( o*./ /11-)-1r cLt4
<br />laNsr!]:r1]!Il.liN!rr!i-A!iErcl
<br />z',y 9sle
<br />I hcrchy annh u cr p.nahy dl !.rjury rhar lhcrc n a con(nr.lion lcnJins +cruy ttr rk Frlormtu of lhc *ort lor *hi.h rht ,lcmii i\
<br />nsucJ (Sfr .1097. Civ C.).
<br />A!fLICANIDEC!2!8AIIA!
<br />I ltErry,nim unJ.r F.axy ol tcrrury.nc ollhc,tllowrn3 lcclararions:
<br />DeBnilrun Pcrnik-Asb.no! Norincalon ftJ.BlRceuhrions (Tirlc 40. Pd6)
<br />_Rc+ircn kttq ol Norifdi<,n
<br />_l ucdiiy nlll rhc Ic,lcBl Esul,rionl Esdding ash.ros ictrilvalm mlappli.atlc r() rhis tojccr
<br />!11 !d 'ry rhlr I hlvc rcad rhN ,nd*artrm ! 1 nrdh hc rh,{ ihfo@ron r .orc.t I .erc ro .-q'ly $ilh lll Ciry ,nd Coudry
<br />.,dn$n cs ind Sr c liwsrcL[ing l0 connruLrion. anJ hcRhy rurh(rizc rqycrmalNcs ol lhrCilya Counry k)
<br />rh)!c nrcrrtr,r'l pfl)F-.ny ntr
<br />Appli(nnl.rAscnlSixnnlu
<br />izu th z4 (<-
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathino
<br />Shear Wall
<br />Framing
<br />lnsulationi Enerqy
<br />Drywall
<br />Ext.i lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Reporl
<br />Flood Zone Ceftil
<br />FTNAL r//l/Jo-F/-.f(,toq
<br />Certificat6 bf dccupaircy -
<br />Notes, Remarks, Etc.
<br />I
<br />,zs
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<br />ID/SIG.COMMENTS
<br />,X..^\
<br />trnlfl's AJJrs
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