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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BI]N-N[R DEI,'ARA1'ION <br />I hqcby amfln u q pdalty oap€.jury lfiar I on eicnpl toh rh€ Conta.rof' Liccns. L* lir lhc aollowin8 .mn (Sa.?011.s <br />Businss dd Prolsion Code) ,\oy Cily or Counry trhich r€qun6 ! pqntn to coNlru.l, all6. nnp!o\€. &rolish o. rcpan oyr} <br />srtu.rurc, pior ro irs issuMcc. also rcqunB th. applice.t for su.h p.ftit ro file a sign d slaldnol that fic or sh. i5 li.ostl r6utur . <br />ro rh. prolGioN of thc Conrra.td s Lic.n*d La*, lchaprd I, Commcncins rvirh S<rion 7000 ol Diliiion I oflh. Bdsin* &d <br />Po&stuns Codc) or rhrt h. 61 3hc i. q.mpl thaclrum dd rh. b*6 hi fi. all.ged .rerption. Any violation oas€ctior 701 L5 by any <br />applica aor a p.mn $bjcB the appli.antioacivilp..alttolnornor.rh fivc lundrcd dol!6 (St00) <br />lLa.BtsE&t:taMEllafta! <br />DECLARA'IION <br />I bd.by amm undo poalry ofpdjury one ofrh. tollowinS d6ltrarioB <br />I haveMds,ill mainlain a c.nilicarc oacoNdr ro s.lf lnsurc aormrk.E corp.nsaiion,6 provid.d to, byssrion 1700 oflh. <br />Lahor Codc ior rhc p6foddc. o ilhc *orl lor {ticb lh. pfiir G isu.d <br />I haveand\vill maimain wortcrr'con'pcnsation iBuranc.. s ,.qut€J bySdion.!7(r0of tht l,bor Codc lor rh. pofonnmc. ol <br />thc wort for Nhich lhis pcnnil is isucd. My wo'ksv compoMtion iBurocc cois axl r.li.y.umbd el <br />.ui3 <br />Poli.yNumbs Exotcsl <br />l.diayrhd in rh. pdaonnanc. ofrh. *ork aor which rhis pdrDil is issued. I shallnol mploy My D.M. i. an,,nDns <br />$ 6lo beconE subj{t to thc *orks coipqsaircn lE*s or Caliromia. dd dsN ihd if I should b€comc bj.cl tolh. <br />sorr6.oop.@rionpovi.io6ofs.<rionlT00olihcLabrCod..lstall.aonhwnhconrplysithrhocprovisioos. <br />WARNING: l'ailorc lo surc Norld' co,npmotio. corr0Sc is unlaqful. d sh6ll subjdt 3n @ployd to dninal pdahi6 dd <br />cilil li..s up ro on. hrn&cd rhouwd dollds (S100.000), i.oddnion to Ihe cosl olcoopensalion. ddaSa a l,ovid.d for rhc <br />Sdion 1076 otlnc hbor Codc i d61ed altonEy s lG <br />IIS,ISELCONIAACIANtlrctASar{l! <br />I hdeb, armn und€r pcaall, ofpcrjury lhal I dn lic€n*d und€. prolision olChaptd 9 (connEnci s wnh Serion 7000) ofDivision l <br />of rhe Rusin* sd Prcf*ions Codc, &d 6y lic@s. is in aull forc. md .ff€t <br />Lic.N. CIN:-Licdc Nuabd: <br />corllaucllon-r,ElDrlc3cllcv <br />I h6eby arild und6 Fnalry 6l pdjury thd rha. i! a .odtudion Lndin8 .smcy for th. palomoEe orlhc work aDr {hich rhi, pdnn i <br />issucd(s* 1097. civ. c.). <br />AITLI(ANI.DICIAMIIO! <br />I hsdry anm unds pdahy oa pdjury on. of rh. lolloslns dd lmrions: <br />D€nDlirion PonireAst sros Noificarion Fcdaal Rcrulari.o (Tn|.40, PM6) <br />-Rcqun.d <br />kud of Nolifrcaion <br />I cdif, rhd lh. a.dd,l r.rul0rioN agddi.8 6b.sros dnolal dc not arplicable lo lhis poje.1 <br />I.dlilithd I havc rad lnis application rhe abovc inlonnartun $corcc1.I alre t. co,nply $irn.ll(-ily and Counly <br />o,dinrnc6 Md srale bss relalinr lo bui ,d hseby aurhonT. rqrcsrdir6 of r[is Cnt md <br />abov. :ncnr io.c{ pro pcny aor in+d io <br />Vp l\) <br />Set Backs <br />Forms/Steel/Holdowns <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />h/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif. <br />/.\ <br />FINAL 12'17-x x.v4J0\ <br />Certificate of Occu n <br />Notes, Remarks, Etc. <br />Erection Pads <br />_I. d oM6 o ilh. aloldry, or m, cmplorc wirh was6 &t rn.n eb .onpdsrion, will do rhc work ed rh€ struddc ! nol <br />inrddcd orofid.d forelc(Se.7044, B6ins and Pr.fsioN Cod.: In. co racror. Lic$c l,u do6 oot apply lo e oM6 of <br />rh.p6p.ny who builds o, nnPlo!6 rh@i, dd sho do6 ech w* hins.ll or h@lf or rhmo8h his or h6 o*T .,nployc6. <br />p,ov idcd lfiar such iIpormIs rc mt inlc'{bj or olIdrd for elc If, lr$as. rh€ boildins or inprcv.tEr is $ld wirhd o.c )d <br />oicompLlioq rh. OrM Buildd will h.v. th. htrd6 of proving $d h. o. shc dil mt hild o, imprve l& Fopqly tur thc p4.* ol <br />-1. <br />d oMd orrh. prcpoir. an aclusiv.ly .ontaolin! { ilh licds.d conlra.rou ro construd lhc F!j..I (Str. 704,1, B6ins <br />trd Proitsion Cod€: Thc Cohracroii Lic€nsc k$ do6 nor applyro an o*ns ofproFny who buildi or nnpro!6 thdNn. <br />and who coniacls for sch projds w naCo 6cto(s) li.@d punuanr to th.Conrracrois Licosc Law) <br />-l <br />@ cxemrt uods Scrion-. B & P.C aorn s r€6on. <br />L.nder ! Addr6: _ <br />,\t,pli.d r or asc r Sitnilur( <br />I <br />=