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. BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BU!LDEII DDI,CAR TION
<br />I h.rhy rl1lnn trnds Nnony of n riury ihar I n cxcnr/ fnnn rhc Conh.ror' l,i.cnsc Lf,{ fff rh. fdl.wirrA rcn$n (Scc 70:l l 5
<br />Businc\s rBi Prclc\si.n Crdc): Atry Cily or Counly which rcquircs a p.nnir ro ( iflct. rhcr, imDmlc. d.nnnish .r rcNt rn!
<br />itucrr.q Fridt' ir\ issuancc. rho rcquneslhc lDplicrt lor suchr(rhir k,lilcasiStrcd slolcEnl lhrrhc.r lhc is liccnsed lunuanl
<br />ro thc pmvi\ions oflhc Conlracroir Liccn\cd ljq (ChrPrci 9. connncrcirs will sccrnnr 7000 of Diricion l1 ol ihc Btr\in.* rn
<br />PronstnsCodcr.rlhrlhcorsh. i{cxcfrpr rltrcrioNundrhc h.e\ r'or lhc ullcscJ crcnrfliotr nyviobrn'nolSsnonT0.rl5byrny
<br />arplicrnr for !I,.nnit srhjcch rh. np!licrDrlorcivillEnrltyol'normorcrhmfivchtrndrcddolln6($5ll)).
<br />-1.
<br />0\ owrcr ol lhc porEny. or nry cmrlorcs wnh w08.s .s rhcir $le omPcn\nrion, *ilt do rh. wort M, rhc ddruto h tror
<br />inrc cd orolltrcd ror t.L (Se.7(!-1. Businc$ ond PmL$ions Gdc:Ihc ci, raclofsLicensclJNdoccnor,PPlytoanosn.rol
<br />rh. rmrcny sk) builds or illllrroks rlrc@n. dd Nho &rs su.h *\rk himrcllor h.rclf.r rhtuugh hk or hcr owncmployc.s.
<br />polidcdrhar\uch ihptuwm r m mt inrctnjdl or otlircd lor {b ll h)sctr. rh. h{iuin8 or in{lmrcnd k eh wirhin onc ,r$
<br />olconllctiotr.iicornrUuilddwillh.vclh.budcnofrxovitrElh hc.rshcdild,t{i or i,qrorc thc pmFn} rff rh. pu{r$ of
<br />-1.
<br />!\owncrol rhcpdp(dt. rtrlcx.lurivclr.ontmdin-q *nh liccn{d contactu* k, $n{dd rtE Prolrrr (Scc 70.lr.8unnN\
<br />and Pnnissh.Codc:ThcConlracror'sl-iccn\ct-rsdocsnorrt,Plyt'anotrncrolPopc ywho hrildsor inr[ovcsihcrcon
<br />ud whd contac( ror su.h piiicch wilh ! Conlracrod9 liccn\ed prrsurnrk,rhc C1, rlcloir Liccnsc lis).
<br />I rnrc:dn,]rr rnJcr S.rri,,
<br />Drrr OPnE,
<br />W(INKFi{S' C(IMPEI\SATIIJN
<br />DECLANAIION
<br />I hcrcby rfinnxndcr Fnalryoiperjur,oncolrhc l(,wint d..lddio.\:
<br />-l
<br />hnvc !.d will mai.rain E C.nirrc,rc of Conscnt b Sclf-lnsuE nr *0r[6 o'np.ns0rion.os pmvided iorbySeri.n]7mollhc
<br />b}xtr codc, for lhc pcrionnanceotlhe wo.* nt whi.h rhcr.rnrit h issucd.
<br />-lhavcnndsillmainrain*orkcd.onwNdioninsuroncc,!srcqundhys..riotr3r0OoflhcljtorO
<br />c. ror rhc NrfotnDNc oi
<br />LL ir is rsuL{. Myworkcr'conDcnsilion insurrNc. tri$ ntrd fricynuDhcr ar
<br />l/."",t\,5 tr^^"t
<br />10a9 Y).}t7 6 l't1
<br />I ccniay thir in rhc pcrfonuncc olrhc sork ror shi.h this p.flnn k hsulal. I shallnor.mlluy an, pcr$r in any nEnncr
<br />v, N to bc.om suhF.r lo rhc *olkctr conlpcnsotion l0ws ofcali&rnia. and rltc rhd ilI should $ccom subjcc . 'laworkrn Ll,dpcnsarioh pnrvkrns ofScclion 3?(x)otrhc ljhor Code.I shrll. I.nhqith $mply wilh rtx,{ polisiotrs
<br />lryARNlNc I'lilurc ro srrc w.rkctr coorF.s.rion .ovcaSc is unlastul. a.d \hall lubrccr an cnrlloycr b 5i'nin,l Fnnlrts i.d
<br />.ivil Inrc\ ul] k) onc huddRl rh.us.nd dollns ($lu).lxx)
<br />Sccli 3076otrhc tihrr Codc. i[crc{ and.lhrrey\ les
<br />,fconDcnslion. drtug.s rs B)vidcd lor lhc
<br />S'tt-t,
<br />L&I'NI!]ILrcNI&$&Bll[!:L Xrl"I(\
<br />I hcEhy afinm undcr pculiyorpcrjxryrhar I 0m lienrn undcr nmvision or Ch+rc. 9 (com,mfrins wnh S(lh. Tuxr).fDivhion 3
<br />or rhc BusiRss,nd Pmicssions Codc, anl my lkc.* il in tulltu c nlcllecl
<br />(,*
<br />\a'e:
<br />c.t7 ?loo B
<br />.F')tlD .-"*".
<br />CONSj'RT]CTIoN I FNDIN(i A(iFNCY
<br />Ilucbyrfinntr dcr lf,tr ryolt'crjuryrhatrhcrcnscointucrinrLnd,n8rS.ncylqrhlpcrfonDn.colrhc*orkinwhichrhnFrnrir(
<br />istr.(liS.. 1097. Cir C )
<br />Set Backs
<br />Formsi Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation I
<br />Roof Sheathing .v'XLtt,t
<br />Shear Wall i-u
<br />Framinq
<br />lnsulationi Enerqy
<br />Drywall
<br />Ext./lnt. Lalh
<br />Brown Coat
<br />lt/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req \
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Ceftif .
<br />FINAL 1 6l:8 ,( 1/,(0 /r1 /
<br />Certif icate of Occupancy l l"/
<br />Notes, Remarks, Etc.
<br />\.
<br />Erection Pads
<br />0/l//I
<br />Lcndci' Ad,lrc-
<br />APPI ICANT NF(]I ARATIoN
<br />I ho$, affm und€r pc.ak y of D.rjury om ofthc iolloqins dccla,alt,n\:
<br />ocmlition Pcirnik-Asbc(os Norificarion Fcdcral RcSularions (Tillc 40. Pan6)
<br />Rcqdcn ktr.r or NolifEarion
<br />-l
<br />ccnily lhd Ihc lcdsral,cgulalions c8rdnrg asbc(os rcmvd!e nor aP,'lkabl lo thk ProFct
<br />-l
<br />.cniry rhar I hivc rc.d lhG applical ioo el sldrc rhdr ih. ,tsvc hlormr ion h coGr I agd ro .omtly qnh oU Cir, a.d Coxdy
<br />ordiMnccs ond Siarc Lawr relaiins to boildang ..6shdion. ud lrrchynulhoia rcprcscnrdivcs oflhis Ciry md Colnryto cntcr u,n)n thc
<br />ohr. trnr ncd pmFny lor m\ncdion pu' F^c\
<br />4Dr(u,or{Rn,sisn.ru* eXk- ,," 9'}r'r8
<br />pcmr,e mne (prinr,: CJos-E^."- q.,,.if
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