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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE lD/srG.COMMENTS OWNER BUILDER DELCARA-TION
<br />I hdcby am,rn undq poally ol pdjury nd I dn .xdnpi ttorn rhe cont.cros' Lic.nse La$ for lhe rollowide r.Mn (56.'l)11.5
<br />tlusin6s and Poasion Cod.): Any Cily or Counly whrch r.quiB a Flnn to codrrucr ah6. inpro\q d€oolnh oi Eptt dv
<br />srrucluc, rior ro ils issu ce, also r.quir6 lh. apPlicml aor sudr p€mil b filc , s,sn.d $ddnot Ihal h. or thc is licmed pwanl
<br />ro rhc rtrovisioos oflh. co.t@rois Lic.n*d Law (Chagrr 9, Commscins snh Sdio. 7000 of Division I ollh€ BGin s 6d
<br />PNlNionsCod.lorlhalhcorsheit.\qnptthd.fro,nmdlhcb.sisforrh€allcs.ddd$ion.Anyvrclalio.ofselionT0ll5bvanv
<br />3pplicd for a p€mn subjels lhc alplicanl io a civil !€aslly of not 6.e tm 6!e hun&ed dollds ($500)
<br />-1,
<br />s oMn olrhc lropcrly, or my €mplo)€6 *ih Nass 6 th.ir $L comps6arion. {ill do th. wo,I d thc sltucrw i. n.!
<br />intodel or ofiEed lor elc (Sd.?044. BEins Md PmlsioB Code The Conltacioi s Licd* tiv do6 nor apPly ro e orvner of
<br />rh€ pmpqly vho boilds or inFo€ rlBod ari who do6 such rrc* hnns.laor hGll or threush his or hr o*n mplovG.
<br />prcvid.d rhat su.h nnrroldsrs m nor iniqdd or olToql ror ek Il hosaq. th€ buildils or ihpovandr is eB wnhin onc yd
<br />otconpldioq lhc O"d.r B{ildd will h.rc ti. bud6 of prelins lhi h. or sh. did d trild or imp.olt th. FoFrv aot ln puposor
<br />-1,6ownd
<br />olthc pmFny. d dclusivelr.o.kacrin8 wnh Lcss€d comado6to coBlruct lh. rojNr (Sec. 7044. BKincs
<br />dd Pr.l6sion Cod.: Th. Co.lr.€tois Lic6s. L.w do6 nol applylo d osnq ofplop€nt \vho builds or impovcs lhd@n.
<br />and who comncB lor such pmj..ls wirh a Co.tado(s) licmd puNwi lo tbe Conlrlclois Licqsc tiw).
<br />_l m.rcmB undd Sdr
<br />IAatrE8S:(AMIIN.:A]!AID[Ct/3dfI9r
<br />I hd€5y .mrm und€r pmahy ot p.9ut, on. oathe aollosins dddalioG:
<br />Ihaveddwillnrainrar6Cdlific.rcofCo6cnlloSelf-lnsurclorMrk.c'conrpenstnn,,6[rovidL!aorbySslion.lT00orrh.
<br />Labor Codq aor lhe pgfomacc of th. {.d fot $hich lhc pqnil b nsu.d
<br />-lhav..nd$ill'nannainwork.6
<br />conrpc6alFn ituuid... s r.quned by S6lion.t700 ofthc L.bo! (od. forih. pdfonDdc. ol
<br />th. uork tu hi.h n s p.flnil ir issued. My worktrt co'rpdsttion insurancc caria and policy n,mbd sc:
<br />PolicyNumb6 ' ExPt€s
<br />Xr-nirr,r,, .['"p-r"-dccorrh. surl lor \ h'ch rhis Psmir is Budl.l sh6ll nor cmployany pc6on r mv mmng
<br />'{ arobc.omcsub|ki ru I h. q o*4' comFnsalivn ld iorCdl'l"mm, mdaalelhar l 'hould bltom.sLbar r'rrh.
<br />*0116' comp.Balio. povisioB oas*lion 3?00 of thc Lrtxr. Codq I sh,ll. fonhB ilh enply virh thos prcvisioN
<br />wARNlNc: Failur€ Io $.ue work6' .omp.Narion cove?ae is unlawful. ..d shall subjccl o mpl6y.r ro dininal poali6 dd
<br />civil fines xp lo on€ hundrcd lho@d dollm (llO().OL\)). in addilion ro rh. con of comp€Nrion. damB6 6 pro d.rl for rh.
<br />Secrion 10?6 ofrhe Labor Code, inrdBl tudanorney's 16.
<br />oOOUo*M
<br />IICENIELCANI8ACIOA
<br />DECI,ASAI]O!
<br />I h.rcb, afmn n.d€. p.nalry o I pdJury dd I m licas.d und.r FovGion ol Chapr6 9 (co,nmocins *'nh sdion 7000) or Divtsion ll
<br />or thc Busins dd Pmfsions Code, a.d fty lic@ is i. atl lotce ad efre.l
<br />q B\r-o r1
<br />,",",p \\Wt [t9, c-,'*.'! \I,L \\$t'Ag'
<br />coNiraucuaxli[ Dldc.AcElcr
<br />I hftby arm u.dd p.mty of Frjury that lhd. b a codruclion lcnding asacy aor rh€ pdlomdcc oarh. Mrl for which rh6 Fsit i!
<br />i$ucd (S€ 1097.Civ. C ).
<br />APP! I(]ANT NECI ARATION
<br />I holty .trm undd paalty oa Fjury oDc of lhc following d<lerioN:
<br />Dmolirion Pmils-tubdos Notificalion feddal Rcsulgtions (Tilc 40, Pan6)
<br />-Rcquncd
<br />Lar6 of Nolifrc.lior
<br />-l
<br />ccniry that $c f.d6.l r.glhtios r€gEdirg sb6los rdor.l de nol .pPl,cabL to lhs projd
<br />B.&" ,n,, , *'. .oo *o appli.ar ion ed srarc thar rh. ah.v. inromarion is cor6t. I asc ro comPlv wnh au cirv a.d counrv
<br />olnrM(6 Md Srar. tiu rcld bs !o burldrs conhd'o( dd hd.by tuthorie r€pr6a$1iv6 oalhis Cnv &d Courv to atd upon tn
<br />rbov€ m6tion€d ploFny lor LBF.tion purpos6
<br />.,.,. \tl1r\ tuAppliotrr or Asent Slgnrl!r.
<br />t done nrme (prinriK
<br />Set Backs /:\
<br />Forms/Steel/Holdowns \ .,4
<br />Erection Pads 1,,,ill -.a
<br />UFER Ground U
<br />SLAB Floor
<br />Subfloor/VenUl nsulation
<br />Roof Sheathing ')a)n ^l , o..:':(?
<br />Shear Wall 7'-1"' I I'I l"-^
<br />Framing Ytltot Ta^x,
<br />ln s u lation/Enerq y ;i-/t*'id ,4J,*)
<br />Drywall i)r,l,,t rt'i4t i)
<br />Ext./lnt. Lath U
<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 />FINAL 4lultn 1 A)
<br />t t)1Certificate of Occupancy
<br />Notes, Remarks, Etc
<br />+
<br />1/ ^0)
<br />,{n -\
<br />,f*i,iVl-
<br />a U^,aa;:*
<br />Wfe4"\/A
<br />L.nd.r's N.n<
<br />-
<br />Len,.ld s Add.s'-
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