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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG,COMMENTS OWNER BUILDI'R DEITA&ATION
<br />I h.reb, amrm ondd !.nalty oa psjury thar I m €rcmpl fron th. co.tractotr L,ic.nF Lsw tor tht lolrowinS r.Mn (Se 7Ol I 5
<br />Ituin6s and Profesion Codc)r Any Cil, or Cou.ly $hich tequts a pqnit lo codlrucr. ahd. imProve dmolish or EIun My
<br />slfucrue. prjtr ro irs iqsuec.. also requir6 rhe appli.flnr for such rsmi ro nb a sign.d slaldn€nl lh.l h€ or shc is lic6.n p6rmt
<br />ro rhe prcvisions ollhc Coorador s Lic.ns.d Law (Chaptd 9, Co,nm€ncias wilh Serion 7000 olDivision I ofth. Busins Md
<br />Prulsions Cod.) or rhar lr or shc is cr.,nB rhdcfrom md rhc bsis lor lhe all.s.d creoFion. Any violalion o I Sel ion 70:l I t b, any
<br />applicdl aor 6 pdnit soblds thc applicanllo.civilpcnahyolnolooe$Mfivehuhdtcddouss($500)
<br />l. 6 oMd oflhc prorEny. or ny mploy6 with wa86 d thcn sk comlEMlio.. will do rh. woir md thc nrud@ b nor
<br />imo\icd orolIdert aor sl. (Se.704.4. BGin6 a,d Prefsions Codd Th. Conl.aclois l,i.dc LiN do6 nor tpplylo orndor
<br />th€ propqly who boilds or nipmv6 lh@.. dd Nho do6 such wo.k him.llorh6ellor rhrough hL 6r ha own cmplov6.
<br />prolid.d rhd soch imI,o\@ols @ nol htodcd or ofddl lor el€. lf, nowoq, lhe tlildi.E or Lnprovemot is $ld wihin o.. )@
<br />ofc.r'pLfion, rh.ol,n6 Builds *illluE ln hrd6 ofFlrins lha h.or shc drd d build o, imProv€ lh€ plopsly aor thc puFs ol
<br />-1,
<br />6 otrnd oath. piordty, en€xclusivelyconr,aclins s'ilh licos.d .on! adou to cocrrucr lh. pold lse. 7044.ltdns
<br />.nd ftoftssir Codc:'l hc contdols Lic.ns. L.N do6 not apply lo a.o*nd ol prop"ny slD builds or inprovd $nmn.
<br />and eho .onrhds for sch pmj€<ls wilh a ColtEclo{s) lice,*d pu6! t to lh. Comrlcttr\ l,i.ft. Ltw)
<br />_l anexenrpl undr Ssti.tr_, B & P.C. aorthis r6on.
<br />!a8xE8!:CArd[EX$IlQN
<br />DECI.AEAIIAB
<br />I hrcby amrm undd pmatyofpEjuryonc oflh€ lollowins d6learioB
<br />-l
<br />hnv.ddwill mdinrain a C.nincalr orcoMr to sclfiBur.lor workeR coto!.nlarion, as .1olid.d for by S€clioo 1700 olfie
<br />kbor Codq for rhe pqfollmc. oalt. wo,k lor which lh. p6mi n isu.d.
<br />,l havcand{ill.r,imainwori€( co'npcnsalion iNurancc. 6 eqot.n hy Sdiofl l?00 ol lh€ Labor Cod., lor d. pqfotlM€c ol
<br />io. imur c€ cMi6 dd policy nunbo e.:$hnh rht pmrir is isue.l M! *orle ' comp,_rEal
<br />S+r.-L-+"..^J
<br />'rf sf e7fo\l(rS
<br />I cditlhar in lhc p.rfomdc€ of lbc voik for whichrhispd,nn is isu€d.l shau.or mploy r*.""L,.-""
<br />s s ro bc.orc !!bjd rc rh. qort6' omp€ns.lion laNs otcalifomia, dd a8r lhal ii I should bdotoc subjcr lo thc
<br />vorl6.onp3Mrio!poviioNols6rronl?00ollhclrborCodqIslDll.fonhvithconplywilntho*pblisioN.
<br />WAn]\tNC: l'ailure ro su€ worla' comp.tration covmgc i3 uahstul. @d shall subjet m mplols lo djdi.al pdslris ed
<br />.ivil fin€s up ro one hundred rhoBdd dollm ($100.0cu). in sddition lo t n ofcomp€nstiotr. don.g6 a providol for th.
<br />Sdion 1076 ofrhelrhrrCod., inrdd md anomev s fG.C qo-r*!^t ga,",", , tt/s/tVt1
<br />I h@bt amnn udd p.fl.lly o f pdjlry lhal I an licdHl u.d$ prolisiotr o ( I (co,n M.i.8 Nith Sdion ?000) of Divisiob 3
<br />of thc BBins ed PmfsioB code, md mylicms isi! rull [ote dd cdacr
<br />.Ib 141 I .L.ZA
<br />I h.ft5! amrm ondr p€oahy of pcrjuy rhar lhd. 6 a.ondruclion Lndins asocy for fi. pdfom ccollhcrvo for stich rhis pamn ir
<br />i$ucd {s( 1097, civ. c.)
<br />APPI ICANT DECLARATION
<br />I hdlby atrmr undd p.nslty of p.rjury on. of lh. a.llosi.8 dccld,tions:
<br />D.holilion Pcmn.-AsbalG Notilicalion F.dsal Rcsuldions {Tirlc 40. Pan6)
<br />Rcqutcd L€ltd ol Nolificalion
<br />infomarion iscotred I arreleco,npl,wnhaI Cily dCouoly
<br />auooliz€ r€rr6cnlaxv6 o I rhis Cn, dd aounly lo old upo. $e
<br />^!,Drta,
<br />rr
<br />^sur
<br />sirn trre ).
<br />P"s*a C-rrvut
<br />*,"-tt/r /rr
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subfloor/VenUl nsulation
<br />Roof Sheathing x.w-11)ftD^ lEpr
<br />Shear Wall
<br />Framing
<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 />I'
<br />FINAL tl nlq lr ,qs/aa,t.l "1)t)tCertificate of Occupancy
<br />Notes, Remarks, Etc.t e
<br />I
<br />IN C.rr.""ro.,X (--
<br />-l
<br />cdiiay that rh. lcddol rcgulatioN resddins sbdlos rcmoval d. .or atplic.blc lo lhis proj*l
<br />I
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