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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNEN BUILDER DI:LCARATION
<br />I h.rcby rllirm undcr pcnahy {)l Frjlry lhol I ancrcmpr fron lhc Contrucros l-icenrc Law fitr rhc lolbwing Mn,i (s(70.r]5
<br />Busircss and Prorc{\i.n cod.): Any Cny or Counry {hich rcqltcs r lcmir ro.ondrucr- llrcr. i6pn,v.. &'nolish or rcn,nJnt.
<br />\lrucrurc- ,rrtr Io ns is\ua*c. aho rcquncs rhc +rlf,nr for sxch Frmr ro llh . lilndl {arctrEnl rhd hc or shc is li.cns.d |Dru!
<br />ro rhc pruvkn,n\ ofrh. Conta.r.r'\ t-i.dni.d ljs (Chuprcr 9. Connneming wirh Sccrion ?0llo ol Divirion .l ofrh. aunn.ss dnd
<br />PrcltsionsCodc)o h.rhc.rshctcxcnlptrhcrcfrodrndrlrhr\islbrrhcrlhgcddr.mlrn.AtryvnnationofSc.tionT0.ll5hy.ny
<br />lpplicaor lhrnpcrmil suhjels ric aprlicotrrro.civilNnrlryofnoliFrcrhnnfivchutrdrcddollffs(S50o).
<br />I. i\ ovrr of rhc pn)Fd!. or ry . rpk,y.cs wirh q aScr n\ rhcir {'lc co'nFn\ari(r,. qill do rhc woA drd rtr Iurm i! tur
<br />i'tndqt or o[.r.d lor s0lc ( Sc. 7O,],r, Busircss Md f,ioLs{hB C.d. Thc C-oftr.ktr-l Li.ctrsc Lnw do$ nol .{ply to an o{ ncr ol
<br />rhcpnr0.ny wtu huikl\ or nnpn,(\ rh.R\D xl s,ho dods{rhworl himsclt or hcr\cllor rhmu[h hh orhc.o* .'npk,yccr.
<br />pmvidcdrhir\uchin,Ir)v.rrnlsrrcnoli'cfdcdorolli&tfor*rL.ll.h.w$cr.rlEburldirgorimpiiN.nr tddwirhinoncrr
<br />ol conliLrFn. thr O*ncr Burtlo sil h c rhr buidcn of F)vnrg rhrr hc or \hc dil huikl or nrJ,r)\t rh. potdy fitr thc ruqms ol
<br />-1.
<br />rsowncr olrhc !tupfly.0Dcxclurivcly.otrir..ri g wilh li.cnscJ.otrt..rors ri..r(rucr lhc pnlccl (Scc. 7(11,4. Busnc\r
<br />.nd I\.f.si(nrCodc'l'hcConrncroi.l-iccnscl-a*(1,,c\notapnlyl()mowncrofftr,prnywhoh!ildsorinlp'o!esrh.rcoi.
<br />and who .onr..k for $.h tmlccr wirh r Co ri.kds) tkcnscd rursudnr rorhcGr racrofs Li.cns tiq)
<br />-lamcrcnr0
<br />undcr Scclion .B &P.C fttrrhiircdon
<br />Dll€ ()*n€r:
<br />rv0RKFRS', ( r )lrrPFnr-a-(ri
<br />DECIAMIIQ
<br />I hcrcby afllrh undcr p.iahyofr(rjuryo.c ofih. f(,lb*ing dcclalations:
<br />-l
<br />h.rc rxl will nDNdi|r Ccnillcal.ofC.nscnrt, Sclllnsorc for *u c (nnl,tnqdiotr, rs Frvid.dforbySetionlT0Oolthc
<br />tjhor C.d.. f(tr rh. p.dortuftc.frh. work fn which rhc pc.mir is h\lcrl
<br />5 hsvc rnd si ll mrinr rir sorkcr' comFnlnrion rn(ur0 tr.c. as rcquircd by Sccr ion !7m of lhc bhor Codc. lbr rhc pcrfomEmc oI
<br />lhc work In whichlhis Fnnil is is$ed. MyworlcB conrFnsari(,n insurm.c ceicr uld lnlic, nu rbcr ec
<br />F,e,,vbqdfL2o', I 3- l-lf
<br />-l
<br />ccnili rhrr ir rhc Dcrr.flMncc oi lhcuork rd wrrich lhisNnnir t i\{rd.lshrllr.lcmpl,)y irypcron in !tryrumcr
<br />w, ns b tf,.o,ft \uhjcci h ihc {orhc^'.omrcn\arion lr*t olCalifo'nir. nd rgr.c rharifI sk,rld hlaom ruhj(r i,)rl'c
<br />wrkci\ ..'nFn\arn)n nmtsi(,n\ .t sccr n :l rtn or rtu trtFr cod.. l shrll. frd lrsirh .o lPly wirh rlxJr pnivti({\.
<br />WARNIN(; l:'ilrre k, vcurc sorlcr co'nnetrslnotr covcrl8c i\ unllslul. rn \hrll \lbtrcr , .'npbyer n, ri'n,nrlJf,ulric\ trd
<br />.n'l litr.\ rp ro on. hrnnrcll rhou\r dollr\ l$ll[).lxn)). tr rL(lrit , ro r
<br />';)",.:'""'*t(t Codc. inrerc{ dd ahomy\ fccs.
<br />/-- tpptt-n,Z
<br />I hcEby riirn u.dcr Ftrrllrorp.rjury rh.r I nm lic.n*d und.r rn)viin,i olClhfl.r 9 (.ommmir8 *nh Sali[ r0@) ol Divi(ion.1
<br />.f rhc Busift\rand Pft'LsinnrC.dc, and,y lic.\c i\ in tull tnr.c trtr|rff(r
<br />-Liccnsc
<br />Nun
<br />f/ 6/ /r c.,*.*,)('72!,-
<br />l(JN[IAIL:UAtLl};lDtlCrllilrN(I
<br />Ihctobyrfirntndcr!.rrlrtofpcaurrrlrrrhcrcisrcon{tc(ionlcndi',9xgcncyntrh.puf,t,rd(rflhc*orktrshichrhistNnrir ir
<br />tr{,.d (s.. ro97.cn ( )
<br />lt_
<br />aItl,t(AlttltDcl BAI]a
<br />I hcrciy rfiirN utrdc. frrlty of pcrjury otr ofth. folhwnrB ddlfitrrionl
<br />Dcnrlitim Pcnnils^sbc(ox Norificrrnnr ftdciat Rc8uhrn s (Tirlc,10. Pin6)
<br />-Rcquncd
<br />l.llcr ol N{iilicnlioi
<br />r l.-nifyrl-,rrh.i,h1".guI n1\'rFU.iinsr\}\.r,,.
<br />1,.,"r, n.r r,.. -,u'nL rnrr,.rrr.,.L nrr,n. ,hr
<br />lridmJn,.ri\r..L'tr.rlrr re r. hu.l'ii1E (cnqnh rhrr. J
<br />.,hl'" *di",sr n.,ncij L" sja(,ion nurn sc\
<br />ADpliMDl or AArtrt siAtrrlum X
<br />r'--it"",-,",p;"t,, !.
<br />, it i
<br />+{et/n
<br />rcomvll arc mr q,plicahlc ro rhh foj6r.
<br />nb\r inaomrion is coEccr l !E a ro coq,ly wirh all Ciry and Couory
<br />nd h.6byrurhoriz rcpr.scnrlrivcs ofrnk Ciry ud Counrylo snrs lnon rh.'zu+1
<br />'"'"
<br />t {ftft*, fua\
<br />Set Backs
<br />Erection Pads
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Depuly Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />I
<br />FINAL z/rt/r{+Xq,)
<br />Certilicate of Occu n
<br />Notes, Remarks, Elc.
<br />5177 t3
<br />lq.l.r . q,,["*
<br />Forms/Steel/Holdowns
<br />UFER Ground
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