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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I h6ebr amrm trnd6 poalry ol lcrjury rhd I M .r.mpr lmm rhc Conlracron' Licens. l]rv lor lhe follosing r.en (5{.7031.5 <br />Busin6s and Pofsiod Cod.)r Any Ciry or Counly which rcqut6 a psnn ro .oBrtu.t. alrd. nnprovc, d.,.olish o? t at dy <br />sruclur4 prior ro ns issmcc. als. requir6 rhc amlicd lor luch Fni b lil. a sisncd $alonsl lh.t h. or she n licdscd pusuut <br />kJ Ihc pmvisions ol rhe contractois Lic€ised t w (Chapls 9. ComnEocins $ith S(rion 7000 oa Division 3 oit. Busines md <br />Prolcsions codc) or rhat h€ or shc is cxmpr lhocEom ed rhc bori! aor th. .lles.d .xmplion. Any violarion ofs$tion 7011.5 by any <br />applic?nr for ! F€mir subjsrrh. appli.anrroacivilpdahyoanoimorelhdfivchu.dhddollds(5500) <br />l, 6 own6 o I lh€ !.oD.ny. or my enplold wirh Narl$ 6 lh.n eh .onpaMio.. siil do lh€ \orl and $. eMUe G nol <br />iorddcd or oII6.d lor saL {56.7044. Bsins od ProlsioB Celc rhc Conrrdclols Licce lrw do6 not apply to d oM.r oi <br />lheI,ipdly {hn huild! oi inpr.!s$mn. dd who do6 such MrI himsell or h6.laor rhmugn his or hd os. nrloy.6. <br />provid€d rh.r srch nnprcvdmrse.nol inla&d or oirscd forsk.lf. hos6d.lh. boildine or imFovmol is$ldGthdoncla <br />orcompkion, lhe o*nd Buildd sill h.v. rtc biud6 of povins lhd he o. sic did lor boild or idlrov. th. pmpd, lor li. purDos or <br />-1, <br />a o*nd oflh. Iropdr, m .xclusivcly .onlroclins vilh lic*ed .o racrou to consrrucl lhc prejed (Sec. 7044, acins <br />md PNGssirn Cod. 1 he Conraciof s l-ic@ t-6w do6 not .rply ro d ow.s of prop.fiy \ no builds or inProv.s thq6n, <br />and *ho.o.tadsforso.nprojdswith.Co.tmlo(rli.os.dpuuu. lo lhc conttcrdis Licde Ltw). <br />_l deic'nfl undtr sNrion . lr. & P.C. ror rhs rc*.n <br />.u.a85[8LCO!I[ENSAIIO! <br />D!'C!4!Al!l)! <br />I h6et y aflinn uo{16 pdalryolpdjuryone ollhc lollo\enl3 dclmlions: <br />t have !d will minrain a Ccn,fic.r. or Co6or lo Scla lrslrc for \rork6 .onpenerioi. s Ponided aor by Sction 1700 o f rhe <br />H;r;i <br />lorlhc psfonnance.alhe *!rt for *hich rhc lEhir is isuc{l <br />will aimain workers compcnsation icumncc. s requt d hls<tionrT00oflht L,bo! Code, lor lhc pdtiJnnd.. oa <br />is isual. My {orke6 conueMtion insur&cc cdid md policy numbs e:B fu-,-l ioaw jJe <br />\rcc i375b2 A o 7 ->t-11 <br />I ccnily thal in thc psfornoce darh. *ork aor *hi.h rhis per nrn is 6u.d. I shall ior dnpl.y any po$n in u, Edng <br />$ as ro b.comc subj*r to rh. \hrk6 compdation laws olcalitomia. ad agrc rhar if I should b€comc suq(r to rhc <br />$6rkds conpNrion prclisions of Scclion 1700ollhe Labor ('ode.I $h.ll. i.nh$irh conrply rilh rhosptuvGiod <br />\IARNINC larlure 16 $u. uork6 compsarion colda8€ is unhwful. dd shill erbjd d onplotd !o omiodl pduhi6 and <br />civil ljn6 ut re on. hu.dred rhoos d dotl6 1$ 100.000). ia oddirioi lo nrc coe otcomp.nstion, d@sd 4 p.olideJ fot the <br />S(xon 1076 orrheLaborcod€. inld6t md a(oru'r: s fs <br />r)r ( t.\R\llo\ <br />I h.rcby atiid uodd pdalq of pdjury lhrl I an licc.s€d lnde prcvlsion ofcha,rq 9 (commmcins Lvirh Sclion 7000) oaoivision l <br />ol lh€ Busin€ss Md Prolsioos Codc. ad ny licme is in flll aorc od cfi(t. <br />?sso t c) <br />I hd.b, artrn ondd F.ahy of p.dury $al th@ is . .\Joslruc1on kndinS .gncy for lhc l,gfotucc of the sork for Nhich lhis ponn i5 <br />is!.d{Sc 1097, Civ. C ). <br />ATII,TIANL2ECIASAIIA! <br />I hod,y arnn und.r p.nalty of psjury on. of lhc lollowior dslrarions: <br />D.dolnion P@irs Asb6ros Notilicat ion F.d6al Rcaulations{l'nE40. Pan6) <br />Reqlt d L.(d oaNoli6calioD <br />I ceniay thal rn€ ledFal rcsularioN Esrdinr GbGIos rdo\ .l orc not applicablc ro this ttuidr <br />I c€nirrhar I hav. r.ad rhis ipplicario.edsarcrhartheaboveinfoflnali.. ir c.rd laSreroco'nply*ilhallcirl,ndcounrv <br />ordinancd md Sb'. tjws rcldiu ro blildin-q conslru ion. ad hr$y aurhJ c reprsc ativ6 olrnh City dd Counr! lo mrd upon !h. <br />rh,vc n,enruncil t()pcnv hr <br />,\pt,liunt or /\scnr SiBnirurt <br />fli cLstt fion qp"€ <br />tt-28-t8 <br />Set Backs <br />Formsi Steeli Holdowns <br />Erection Pads <br />UFER Ground <br />Subfloor/VenUl nsulation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />ln s u lation/Energ y <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lVasonry <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />FINAL 7/tU<hmqo fcL a+{+^) <br />Certificate of Occupancy <br />Notes, Remarks, Etc <br />SLAB Floor <br />Pool Fence <br />Flood Zone Certif . <br />"".' , -26'lg <br />o*"'It'29't/'#,ffi; <br />t .nil.rs Nim. <br />- <br />L.n,ld'lad&d <br />-