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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE tD/stG.COMMENTS OWNER BUILDER DELCAR TION
<br />I herch, ainn lnder ltnlh, {)f prrjory rh,r I d crc'npr ft.d rhc C.nncloF Liccnrc hw for rh. lollo$iie rc,$n (scc 7)l l .t
<br />Busincsl nnd Ptufc\si.n Codc)r Atry Ciry or Counry *hi.h rcquncs . ncflnir lo condruci. alrcr nnF)rd, dcnnrlhh .r rct{n roy
<br />struL1ur.. Frhr ro ils hsuancc. ols rcquteslhc lpplicanr ior suchlcrniir ro filc ari8tud sdc'm dd hcor she G liccnscd ,,tr6urol
<br />b rhc pn,vi\nms otrth Conkdoi \ Li.cnscd bw (Ch,pr& 9. comincncirS silh Sccrion T()OO oi Divirion I or rh. Busnt$ ,tr,i
<br />Pnrfcs\n,ns Codc) or rhrr h.o.shc kcrcnrt)l lhcrctunn d lhc bNis lhrttu dlcBcdcxcnpri(nr Anyvid"rionofSccliotrTlr:ll.5hyany
<br />applicanrlb.npcmnsubjcckrhc.pplicanrto{civilpcn0lryolnornFrcihanfivchxndnddoll s($5(D)
<br />I. * .Rkr or rhc pn'Fnt, or ary cmplolec. sirh w.sc\ as rhcir soic s ueosar ion. will do rh. Q.trt ,rxl rh. (ftt@ is ml
<br />inrcndcd or olcred for solc ( 56 7ft4. Bu\ines ud Profcsionr Codc Thc C.nkxclor's Licctrr Liw drcs rcr aplly h rn o$ cr of
<br />rhcln)rrny who huildlor iq,ruvcs rlErsn. ifll sho des ssh tro* hnnscllor h.rrlfor rhmugh hi\ or hfi own.rployccs.
<br />p(,vilcJ rhri s,ch nnlrovcnrnh lrc nor i'ncidLll or orcr.d f(n s c ll ti,scvcr. rhc buikli[.r irnn*mrfl is $ld wirhinonc Fnr
<br />ofcorryklion-rhc()wncr AuiBcr trillhf,vc rhcfidrdcnotpmvingrtul hc or sh. diil fr, t ikl or imlmrt thc tmlEny f{n rlr puqrs ol
<br />,. rsouDcrofrhclrolc y, rmcr.hsivcly.onka.rir! wirh li.cn\cd.otrk&tns b con(rud lhc nmicr lSdc 70:14. Bu\i"rs
<br />rl ADlissnn C.dc IhrContlct,tr s Liccnsc l-ie docs oot applyii' !nowmrol prop.nyqho buildsor nnPnvcs lhcrcotr.
<br />r l who cont rr \ f(n sDch projcc( wirI a Co "dcttrl\) li.cn$d NrsuMr to rhc Conrrucroi s l -iccnsc l-n* )
<br />I JncxctrrDr,trdcr Sccr.on .ll &PC
<br />IIICIdAAIIOtr
<br />! hcr.by rflnmundcr pcnllr, ofpcrjury.nc oilhc a.llosin[ dcchralio!\:
<br />I havt rndwill trEidrir rCcnifrcolcofCo.scn o Scll.lnsurcfn $ork6i comFnsdion. nr pmlidcd foi byS{rion lT0Oofrhc
<br />Ldhr Codc.li,rthd p.rfornratrft ol rhc trork t'r which rhc !.mil is issucd
<br />_l hrvc!tulvill n{inr!i', sqkcrs' con,rcn\srn,n in\uran.c. a\ rcqun d hj_SNrir :1700 ol rhc liborCodc.li,rrhr n..roflnri.td:
<br />ihc $or[ nr $hichrhi\ pcrmir ]\ i*xcd My\r.rkds .rnfrtr\rfon r\urm.ccraicri |oli.y nunrhcr rrc:
<br />PolicyNumhcr:-
<br />-lccniiy
<br />rh{l in rhc pcrfornnncc ofrhc *ork f(r *hich rhi n rmn is i$ucd. I ihlll nol ctrlploy rtry pc6on in any manmr
<br />n, a$ ro hdrft suhj.ct k) th. *o.kcn .onlrn\lrion Llws ofcllilornin. anl aglcc rhrr if I rhould h.co r \uhjccr to lhc
<br />wo*c^ conrn n\arion F,vhions ol Ssrion :1700 of lhc ljhor (ld.. l shall, fonh*irh .omtl, vith rhoc trevirions
<br />WARNIN(;: failurc lo {curc $orkcr cnmpctrssrntrr colcE8c ls nnlx*lDl. dnd \hall suhjc.r ii .mPloycr ro qiminll Fnrlris and
<br />civil fincs up ro onc hutrdrcd lhousrtrd dollrs ($llxr.(xxr)- ir andnion n' i { ol ..nrtrr\rf.r. damixc\ r\ nmriddd r(tr rhr
<br />S..riotr:l076ollh. ttr,h{ (ixl. id.'rn rfdrrrtrtrry \ L.s
<br />Drte: pplldnt:
<br />t)t:(1,\R\r()l
<br />of rhc Busi'rc*anJ Pn)fc\\i(nx Codc. r 'nyl'cci\t n
<br />'n
<br />fullnmc arklcfl(l.r
<br />clllsIaI]quoNrENDlNcaaEN(I
<br />I hcr.by,flrnnuMcr F.rhy or pcrjMy rh{l Ihcrc n s !_on{ruclion lcndins ascm, nt rhc pdnoflnncc orlhc Bork iin $nich this p.roli n
<br />tsucd lscc 3(I)7- Civ C ).
<br />AITLICANLD}:CIAM.IIO!
<br />Illnhy rnr! dcrpcfulryottrrjuryoncoftulolhwin8ncchrrtions:
<br />D!mlirion llcrmir A\18(o\ Norifi(ibi ttd.ral Rdlulxrtrrn (lirlc {0. Pin6)
<br />-Rcqutcd
<br />l.tre, of Ndifsrirn
<br />-l
<br />ccnify thlt rhe fcdcEl rcsllarioni Esadins ashrtos ftmvnl m nor iptlalblc lo lhn pmj.Tt.
<br />-l
<br />e.ril, rnor I haw rcld rhiq atpli.,rioo &d sarc rhar rhc rbow i.fomthn iscorel. I.sre locon ysnh,ll Cily and Contrry
<br />otrlimncc\ 0nd Slnlcljusrclarin8 ro hui and hmby Nrhorizc rcprcsctrlrtives oflhn Cilylnd cl,utrry lo c.lcr u!,.n thc
<br />rhrc f, toird pn,frny lnr nr
<br />,{pplic.nl or A[cnl Signtrtum
<br />Set Backs
<br />Forms/Sleel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/Vent/l nsu lation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsu lalion/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />Iblzuft hfnlrf^
<br />Certificate of Occu n
<br />Notes, Remarks, Etc
<br />Pool Fence
<br />FINAL
<br />j
<br />I icctr\c Ch$ Li..n\. Nurrh.,
<br />I)trrc
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