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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE OWNEtr BUIt,DER DEt,CARATI0N
<br />I h.r.by rllhn unil$ Ptnilry or p.rlury rhdr I m cr.mpr rrcn rh€ Conrdo6 Ltcn* L3$ rb, lhe followins eN,n ( S( ?0:l l 5
<br />3urin.\s ind Profc$io. Codc): Any Ciry o. Coutrty rhi.h rcquics ! tcrmil t' c.nndd. ,lrcl im[ovc, iL'mlkh ,{ rcnrn ,ny
<br />nrucrurc. I,itrn' irs issuamc- ako rqut i rhc spplicor for such Frnir ro lilc r si8kd sarcmni (hrt lE or shc is licenrd purulnl
<br />ro rhc novnions of lhc Conhcroa\ l-iccn{d liw (Chaprcr 9. Conmcming wirh Sc.rio. 7000 of Division I of rhc Busincss and
<br />ProfcrsionsCodc)urrharh.orsh.iscxcmprrhcrcfromrndrhcha\iJfitrrhc!llcsly.lcrcnrption.AnyviohlionolSccr[,n?03l5byany
<br />lDpli(n fo! a lcrnril subjcch thc arpliconr lo acivilpenlllyoinot morclnon fivc hulldad d.lla^ ls5m)
<br />l- trs ownu.fihc poltny, oi ry.nlroyccs wirh wrgcs ai lh.ir \olc .onDun\{riotr. will do rhc m.k:ud r1_. srBruE is nol
<br />i.tctrdcd or oflarcd ror elc r 5(.7()44. snslnc$ ,nd Pmlcsions codc: l hc Co radoi\l,ice.scli$doesnorapnlyn,aiownfor
<br />rhe pmpcny *ho hildsoi nrrrov.s rh.dr. dnd wlb d*\ \!ch *b* him{lror hclscll or IhouBh his or hc, own .mpk,yccs.
<br />proviJcd rlur such i'nprovcEnh m nor inrcftkd or onLrrl lff srlc ltl how.Rr. rh, hoildir8 or inqorcmnr is sold wirhin oE
<br />'wof.ompldtr rhc Owncr suild.r vill turc lt* turdcn oI povin8 rh,l he o! rhe Jil [n tuili or inqD!. rhc ptu,rit ror ItE pu{r{ .f
<br />-1.
<br />!\ o*rcr oi rhc pmp.ny. am ciclu\ilcl, conrrlcr ins *irh liccnscd conk(tr\ t, co {tu.r rrr pr,i{ (se 7t}14. Buiirc\\
<br />and trD,tsi)n Codc: Thc Cdnr,a.kr'rl-i..ns. Lrq docs nor aprlyk, ano*ncr offl.pcnysho builds or n.froves rhcrcon.
<br />,nd wh. coNn B loi such tmj.ck wnh 0 Od Bdon t licctrsd puNrnnr ro rhc Conrrackn\ Liccnsc li$)
<br />l, n.\c 'rr u (Lrr S..ri(rr
<br />,"r.,-5-2a::1Lo"Ad
<br />UI!I.!B]TIIQ!
<br />I h.rchy rflnn undcr Fnrlyol pdjury orc ofrhc Iolk,sir8 dccharions
<br />Ihrvtdndwilltuintainaccnifr.rcor(ronr.lrosclllnsurcfn*orkcn.omnnsalion-a\pmlid.dfttrhySccrio..u00ofrhc
<br />Ltrtxtr Cdrq f(x rhc p.rf.rm. ol rhc work lor rhth lhc |)cmn ( issucd
<br />I hntt itrd rill.mi rin polkcri conrD.trsrlion insurancc.0s rcquircd htSc.rnr.lT(X)ofrlt l-tbor Codc. fn th. Frlomuncc o{
<br />rhc sork hr which lhis pcrmilis hsucd. My *orter' comlcnsal ion insurln.ccxdcrr Fni.y.rmhd ml
<br />PolicyNumb.r-
<br />_l cenily rh3r in rh. pcrfortun.. olrh. qork rrr whi.h rhis l).rnir is i$ncd. I shall nor cmtloy lny Frv,n in rny tunNr
<br />b s ro h.(,m suhFr rorhc qoircs' comFns.lion laws of Crli'omi.. andu8rccrtarirI stxrlld t comsubj.crrorh.
<br />q ork.ri ...rp.trs,ion pmvisiotrs ol Sdiotr 3?fti of rhc tjho. Codc. I sh.ll. lhrl h$ilh unnnl, wirh rhos pn,*n,n!
<br />W]\nNlNC Frilurc ro Burc workcn'conEnsalion colcnse is unhwt!|. md \hrll sxbjd an cmploitr lo aimnrl lcullics and
<br />civil fitrcs uf r. otrc hundrcd
<br />'housand
<br />doll ).00Or. in a(liiri,nr b rhc .oi oI co rN ns,Lon. dmu8.s ns prcvidcd tu lhc
<br />s..rn, llrT6ol rh.ltrhoraod. lnr.rc(u{lrr
<br />"",",-5 -2 t/ - / I
<br />I hcrcby alfird undcr lculr, of Frjury lhrt I rn li.cn*l undcr ptuvisdn nf chlprcr 9 (.on mncin8 wirh S<i hn 7fix)) of Division ]
<br />.f lhc tlusirc\s md Pmlcsion\ Codc. dd hylircns is in fullfor-_ axl clla.r.
<br />SI,N5IAI&NONIENI]NI,i.AIiENI:I
<br />I hcrchy afinn ulrdcr Fnllryofp.rjuryrhd rhcrc is,..nstuclion Lidin8 a8ctrcy rb. thc l).dbrmncc of llNork r.r which rhis rrnrn ir
<br />nsucd (Scc.1097. Civ C )
<br />ATTIIIAIIDECLABAIION
<br />I h.E-hy:'flinn undc! Fnally of pcrjur, o.c olrhc fdlo*ins dcclaralion\
<br />D.nblirion PcrnirlAsb.slos Norific0rion FL{cral Rc8uldions (1irlc.l0. P 16)
<br />Rc{tuircd lrirn of Norifi.ario.
<br />-l.crlilylh
<br />rhc lcdcrulrcguhrions rc8 dinstrsh.no\rcm.vrlrrcnor"ttli.rhlchrhitfrolL\l
<br />I (cnil.v rhrr l havc rcxdrhn rmlicr!otr dnd { rc rhd rh. ahovc iitunnnri,n il..nccl I rgra l.c.mply!irhrllCiryr dC.unly
<br />onLnxnr.\ xn,lSr31.I r\s rc arn,g r hu'ldtrrr cotr{nr.hotr. ud hcroh! rurho rizc rcrcscnrarilcs olrhh Ciry and Counry tJ cdd ulbn rhc
<br />rtxtrc rntoNrl fo|{ny
<br />,\ppli( nr or \[ul Sirnrl
<br />6*/r fo-va /? a" h t, " z.
<br />^" -5 .-2/-79,
<br />Sel Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Beq.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />ll ,t
<br />FINAL ///o// v .LM.
<br />Certilicate of Occupancy
<br />Notes, Remarks, Etc.
<br />ID/SIG.COMMENTS
<br />kndcf ( Addr$
<br />UFER Ground
<br />Flood Zone Certif .
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