|
BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE rD/srG.COMMENTS OWNOR BUILDER Df, I,CAR,ITION
<br />I hdcDy amrn trndd pcnaht oa pdjury rh.l I an cronpr iron rh. Canr,cro6 Licdc tAv aor th. follo\eirr res (Sa 70l l 5
<br />Busin6s md Profdion Gdc): An, Cny or Cou , \rhich rcqrnG a Fmh lo conslnrcl, alt6, irprolc d.holish nr E!6ir My
<br />srru.lue, prior to ns isuancc. al$ r€qutB th. .pplicor lor strch Fmrit to 6k ! sisn€d srarddr lhd he or she is lic.6ed p@&r
<br />ro !h. p$!isio6 oilhi Conrdcrors Lic.ns.d hw (chapn 9, Comhcn.in8 wnn Sdn'n ?000 of Division I ol rhc ltusins and
<br />Prolcsions Codc)or ihar h. or she is.tempr lhr.fiom &d rh. b6is for rhe allcscd.lmplion Any violdion o f sdrion 70r1.5 by a.,
<br />applica"rlor.p.mnsubjdrsrh.arplicantroa.ivilpenaltyotnornD(rhefiv.hundraldollds($500)
<br />l, 6 osr6 of rh. prcp.ny, or my cmplorG sith $ as6 6 thcir sl. smrEnelio.- * ill rlo th. *ort and rhe shdN i! mr
<br />idd(H or olI6c<t a.r el. (s< 7044, aosin* dd Profdiore cod.: Th. Co,tadors Licds. Law do6 not apply lo an 0116 ot
<br />thc Impe! sho blilds or nqxovd thd6n. md $ho &6 such \orl hiBs.lfor h6.1lor rhreuAh his or h6 oNtr c,nrloys.
<br />p,ovidcd lhal slch nnIrovmols s€ lot hlod.d or olM for slc !r. hoNoE rhl U,ildiry or inprortddr i. $ld wilhin onc ,a
<br />oaco,nplelion. th. Ornd Blitler sill har. lh. buidm oap.ovinS dal h. or she did not hrild or impror€ lh€ prcpdy ld lh. purpoe ol
<br />l. 6 own6 oarhc Drop6ly. m cxclGircly co.'lraclins silh lic.ud cotrl@do6to co.nNd rh. Fojd 1s(. 7014. &Er6
<br />dd Pl!tosion Co&: Th.contmcrors ticns. kv do6nor.p!lyro uoBns ofprororyNno buildsor improvdrhd6n.
<br />and trho.o 6dslor!!chPr.j<l!snhaCodnlo(s)li.dEdpunrdtorh.ContrcioisLi.ffiL!w)
<br />I @ erempr undd sdrio
<br />uaBtr!8a.CAu$ll rO!
<br />DECUAAIIO!
<br />I !d.by afllm undd pdahyoapcluryon.ofrh. follosin! ddlararions:
<br />I have a.d *,ill naiorain a Cariicarc ol Co@{ lo Scll lBun aor (6tk6' .om|ra,!ion. a prcvid.d ior by Ssttrn 1700 of th.
<br />Labor Code lor lhc p6iomdc. oflh. Bo,k lor which lhe Fmil is isu.d.
<br />lhdv.nndwillnaimainwork.rs-conrpeBarioninsfia.ce,srequtedbySalionlT00ofthct,aborCode,lorrhepra.mmccol
<br />lhc wort for vhich rhis p.flnil is isscd. MyNork6 comp.NIion insurecc carir dd Fnicy numbd d.:
<br />I colirylhat in rhc p.rrorman.. ofrh. tr6rk lor shich rhi r.nnir is issu.n. I slrll trol onploy any pqson in any muns
<br />e6lob..onr€subjdrorhero*c'comD.nsalionla*'solC;lifornia,andasr..lhaliflshouldb.c.m.stbj.ctrolhe
<br />No*s comF.slion provisioB olsrlion:lTO0 ofrhe libor Cod.,l shall. aonh*nh.omply $ilh rhos pro\isiotrs
<br />WARNING: l'ailur. to sur. work6' comp.Galion cordase is uola$tu|. dd shall subjcd e oplo!* ro anni.al ps0llis ed
<br />ciril lin6 rp ro onc hund.d rhousnd dollm (llCO,000), in ..ldirion ro rhc cosr ol comp.6ar ion. .lan.gcs a p6rid.d io. th.
<br />I hdcby anim uhds p.nal(y o I pejury thal I dn lttrrn und.r tionofChaptd 9 (co'nnBci.s wnh Se.rioi 7(J001olDivision l
<br />of thc BusirB a horEsiod Codc. dd my lictue is in lull for.. aql .lfor
<br />C-r0 s8?068j -zz-/b
<br />! h*by amnn u.der F.hyofFju.,lhrt lh@ isa co,nrudion kndiflB.smcy hr rh. patonnmc. olnE $o for shich lhis pd'sit b
<br />i$ucd (sd. 1097. Civ. c )
<br />aftl]caNr_0[Qdaarlo!
<br />, h6.h9 afrnn unda paally of p<jury onc oflhc following d(lamlions:
<br />D.mohion Pmn$Asbdros Norincalion f.dd,l R+ularions (Tn|.40, P.n6)
<br />R.qut€d lnl6 oaNolilic,lion
<br />I cqrity rhar lhc fsd€ral Egll ions rcsedins sbelos rmoval d. nor appli.,ble ro rhB tiojer
<br />-
<br />I cdiry rhol I hw. r@d this application ad srar. rhd th. .bo!c in fomdion is cod..l I rarfr to onlPly $nh all Cny and Couly
<br />o.dinanc6 ed Sut. lr* Ghtins ro building coBrtocrio., &d bd.by ldhort rcF6ahtivB orrhis Cny Md Counlyl. dts upon lh.
<br />abovc 'nohon€d polllnt for
<br />,\ppli.rnr n, ,\gcnl Sign{ture
<br />t4epa) *"-u LDoal
<br />S-zs* 1b
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subfloor/VenUl nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Fram ing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif.
<br />/t
<br />FINAL q/r//z ,-"ffi4 )
<br />Certificate of Occupancy t/' ,t-, -
<br />Notes, Remarks, Etc.
<br />Sdlior 1076 ofrh. Labor Cod.. inl661 md anorcy s f.6
<br />""",3-23-/t"
|