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BUILDING. INSPECTOR RECORD
<br />COMMENTSSITE.WORK DATE
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Floof Sheathin
<br />Shear Wall
<br />Fram in
<br />lnsulation/Ene
<br />allD
<br />Ext./lnt. Lath
<br />lVlason
<br />Pool Fence
<br />T-Bar
<br />Handica Re
<br />De ut Final Re ort
<br />ineer Final Re ortE
<br />Flood Zone Certif
<br />/FINAL
<br />Certilicate ol Occu an
<br />Notes, Remarks Elc
<br />lhercby,rtrmundcrpcnallyofrerjuryrhdlmcicnyrmrnrhcC,n!id.ro$t-icdn*LiRr'orrh'rolloqingrcdsnrsaT"rlS
<br />susim,; a"d PtoLsi;n C.,1.): Atry Cily ot Counry shich rcqrncs a Dcnnn ro
<br />'onnrucr'
<br />rl'" impn'v' dcnnlnh nr rcr6t lIL
<br />srtucrud. prkr h ns n\uatr.c. rho rcqutcs lhc olplicanr ftr such Pe!trir ro ilc a siancd {crunr rhd trm sht i\ liftnEd promt
<br />lo rhc pnNtion, ollhr Co.taclols Liccnscd liw (ChrPlcr 9. Commc.cing wnh Secrbn 7{xx) ol Dirision I or lh' Bncincs rnd
<br />pnfcssnrns codc) or rhotrf, or shc is cxcnl],l lhcrcfronand ihc b,st for rh. alhscd cxe.Drion Any riolmion ol sdion 7011.5 by!.y
<br />rtplic.nl lbr tr pcrnrir snbjalslne aplliclnrroucivilP.ntrlryofnorn*rh fivc hrndrcd dollaii ($5fi))
<br />-1.
<br />( .*ncr ol rhc rroFny. or nr, c.Dloyccs wilh sLscs ds lhcn $k compcnsrion. will &r ttt *rk dd lhc nndurc h tr
<br />i*"r"a _ "n*"a r"i *i ti- roia. susi.css ana norcsions cod. Th. conrru.ktr,s Lienr tiw docs nor appry ro an own.r of
<br />rhcpmFny wh builds or nr{mv6 rh.@n. Mtl who dG $ch wdr hinscllo, hoMll'or rhmuBh hn orhfoNn cn{krv'cs'
<br />p-iial -r rrgr .u.r' in{mwmds irc ml hrcd{n or orcEal nn elc. li hoeekr' ltE buitling or inryotcmnr is stl eirh'' orc rw
<br />ll codtkrk,n. lhc Owror Brilil$ rill hlw Ihc hxdc ofloving rh{ h. or shc dil nor build ot inlProlc rhc J'mIEn, f'r rhc !uqF{ of
<br />-,.
<br />ur owDcrolrhe propcnx ome^.lu$vclyconlBdnrg *irh licen\cd contacloB t' mnslrucr lh' Pm,ccl (sco 704'l Btr'itu{r
<br />ia p.,tt*i, cna" rhcC,,r,tcrolsl,i.c.3cL,wdcsnoraPplvloanown.rofPrcPcrrvwhohuildsotinvrovcsrhcrcon'
<br />and sho (,nmds ror suchprcjds wirh ! c{,mtucu,ls) liccnscd Pu6uinr to rh. C.Nacrois l-&ns Law)
<br />()\vNt,tR lr( ll-l)lill l)lll ( r\ ll]\l Il)\
<br />I anr.r.n,I utr(r.r s..ri{tr
<br />wo{I<rILs' c()lllPFNsaTloN
<br />DEILISATAN
<br />I hcrcb, alfirm undc, pcMlty of P€rjury onc ollh.lollo*irB dahrarion\l
<br />lhnvcaduillnBinlainac.di.farco'con*nlloscll'lNurcfitrsoltcr\.colFnsdio.,$lmvn]cdi'orhyscclion:]700oflhe
<br />Litrr codc. Ior rh. r.rrormrcc ofrh. *o* for which rhc Fcinrn is h\ucd
<br />I hav. atrdwill man ain wortfJ conlcn\arion iNurincc. a\ t qutcd hvsNrion l70Ooftht btlo! Cod' forttu p'rr"mmc 'r
<br />'hc
<br />wo* lor which disp(mir is hsuci. Mywo cR compcnsarn'n insuraEc 'ricrund loli'v numbcr d:
<br />\r R r,rrl' sta
<br />2\ri5 5t 6/lf)
<br />l..diiyrhtrlinrhcpcifornnnc.trhcwolkforwhi.hrhhlcmir N issucd l\hnlltro' cn[hvrnvPcrm in iovnunmr
<br />*.u't i.* *r,i*iu,,r'" ".rkc!i co'npcns rion l.ws olCnlrroari0. lnd rstrlhilil l shuuH hconx \uhjccr lolh'
<br />uorkc con+cnsriionnxivsionsotssrionr?Lx)olrhctrborCodc-l\hrll nn h$irh '\nnllv s irh rhor Prcvisions
<br />waRNtNc irilurc ro suE workcs, co rtE!\arnnr ..vcrusc is untn$rul_ md shntl suhrcr ai c.Dloylr r. fimiul ,ctuhics lml
<br />civil 6trcs up n, om hundrcd rhousnd doll3rs (SIIX).mor' in nddirion lo rhc co{ oI conPcns'riotr d!'tutc\ !s prnvil'd lnr rhc
<br />sdriotr 3076 ofrhc bhr Codc. inlcrcn and unorry s lcct
<br />D,,,, . 712e, I t3 rpprior, X
<br />DECI.AE{IION
<br />ll!c[b!,lii|nUndcrPtndlyolP.rjolythlamliccn*d[klcllr,vi\n{olchJl)lcr9((nnnrrcin!qithscclionT(Do)ofl)irisiul,]
<br />ol rhc Bu{irrssrnd Pn)fcsionsCodc, aJxl mvlic.nsc
<br />^
<br />in tu ll l6.cc rd clli\r.
<br />.t0 ltc3[
<br />II'ISIBI]!.IIONTDXDINIJJCEN.CI
<br />lhcrcbyaflnDUndcrPcnallyofpcrjuryrtrorrtrmi*lmrruoiulttrdil33!...ylollhcp.rronmnceoflhc(orkforwhi.hlllis.a.nlilis
<br />i\{rdiSe :1097. Civ. C.r
<br />"",.' 7 /25116 c*,.*,*!
<br />L'dclsNrm:
<br />lxnd.rr Addlcss
<br />t ,nr i'npcdnt !trrI,st\
<br />A}]IJCANI.DECI,AM:III]N
<br />I lEr.hydinn undcr lxn y olncrjury om of rhc t Uowing dcclald(ions:
<br />Dcmliri.h Peirnils Asbcsros N.lificarion FcdcBl Rcr!larions (Tillc 40 Pd6)
<br />-RcquiEd
<br />L.lrer.lNolit'cdioi
<br />-l
<br />cdiry ihol lfic Ldeml t BULl ioN mgtrding slEdos rmvll arc nor t,',tlica!k ro dG nmhcr'
<br />Z4l ccniry lhil I lwe rcad Ihis qtpltrriotr nrl narc rhai lh.0bore int rrulion n con'cr' I uxe bcomplvwirh lll cnv and counlv
<br />-odinarc6;.d sto,c tj* EhtinS io buitdinc consrructio,r. $xt hseby aurhorizc rcprcrcnBtncs of rhic cit y and counry b cnrd utrn
<br />'lE
<br />ArDri.mtor Artnl sixtr{tufu
<br />^.f,cm,iree nsn,r (pri ): ,/' ZtJft
<br />^,",- JlZS/1fi
<br />IEEIT
<br />Brown Coat
<br />bilO
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