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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG COMMENTS OWNER BUTLDER DELCARATION
<br />I h6.5y arm md.r Foahy of p.rjury rhal I m cxc,npl iom rh. Conlracro6' Lic.ns. Il1v for lh. follovinB llen (S( 70:ll 5
<br />ausinBs and Profsion Codc): Any Cily or Counly which t.quir6 a Isnil lo .oturtud. alrq. impmvo dotrolirh or r.?air ev
<br />srruclue priJr Io ns nsu@ce, .lso requn6 thc applt l fo! such rsdil ro 61. a signcn st.l4cnt llldl hc ot 3h. is licoscd pmudl
<br />ro rhc pmvisions ot rhc Conlhclols Lietrs.d b* (cbaple 9. Conmcn iis wi6 sdrion 70C{ of Dnision I olthc Busins d
<br />Pmiesions Codc) or $ar he or sh. is cr€mpl lhdctrom dd lh. bdsis tut lh. .llc8.d cxoPlion Anyviolalionofsalion?0ll t bv anv
<br />lpplicafl ao. aFmi sbjdb th. spplica toacivilp.nahyofnormor.rhmfi!.hund,.ddollds($500)
<br />nh-E^ "*"* * rn" **y, or Dy mployG wnh x as6 6 rhcn sk corpc.sarion. will do rhc wrk axj rhc srnk]tu. is nor
<br />i.rodcd or oftd.d for sh lsa.?044, Bsins od t'!ol6'oB Codq Tnc Conltscloas Lics. lr* dod nol 0pPly lo d ouo of
<br />ihc Dmp6ly who buil& or inprev6lh6&q &d {ho d.6 soch sort hins.lf or h6.1aor rhrco8h nis or ncr oq tnploy.6,
<br />provided rhal such nDporodrs e nor i 6dql or o,Iq.n for el6. lf, howeE, $e bqilding or inlxormql is sld wirnin Dne ta
<br />ofompldion. thc O"nq BuU6 *ill hav. thc htr.td olprovins rh, h. or shc did mt boild or oFov. lh. Fbpdty for thc ptrpos ol
<br />-1.
<br />6 oMs of rn Fopdly, m .xclsivcly .oonoclins wnh lic@d .odtrtos Io dnslrud lh. rrojdl (SN 7044. BBinG
<br />.od Prol6sion Codc: Th. contrdols Licm. tj{ do6 nol lpDly to m ow.cr ol propdy *no buil{Ls or improv$ rhd6..
<br />md sno corbds aor such prcj€ds wirh 6 ConElcro(s) lic6..il pnuu,r lo ln. Cohtr.rors Lic.6. h*).
<br />_l mfi.nfl mdd sario
<br />DECIABAIIOI
<br />I hd.by rftr,n u.der p€nally of psjury onc oalhc follovi.s d(l*atio6:
<br />-t
<br />h,v. md will maihtain a Ccnificalc of ConHl lo S.ll-lcu. fdr lotkgt conlP.neri.4 as F!!id.d aor by Sdion 1700 o t th.
<br />Labor Code, nn lh. pdlomec. olfic wo* lor vhich lhc p6nil n $!.d
<br />I have.nd vill h.inr.in wor*.rt comFNarion iNuEn c.6 rcquiEd bySction 3700 ofthc Labot Codc. for6. pdfom c.ol
<br />rhc rcrt for vhi.h rhi. pdiir i! isr.d. My work6i ompm$tiofl iNur&.c .{nd ard Fdlicy nlmbe e:
<br />Policy Nunbo:-ErPt€
<br />W|A&.^,r|nn,"rn *,r.fl uceorrhe{o ror qhrhrhis!.mn i i,sue{.Ish.llnor onployanypd$n r mymdns
<br />T s 6bb€romc blarrorh.*o 6 corhpeN! on I.ws ot Caliaomin. dd aEr€ $ar if I shorld b..om€ subj.d $ rh.
<br />tro s L compsdnan flacrn1 of sdtn l?ou ol rhc Ijbor ( ode. I shall. Ln hq h o,npl, *
<br />'rh
<br />rho* I'rc\ ti. n'
<br />I \tARNlNc Fa'lurr ro *de 10116' .onrpolsar'on covccr. i! u.l.wful. e,l shall slbjsr d @ployd o Giminsl poBlri6 dd
<br />I n',1 fins ,n ro on. hundrcd lhosd 'joll6 I t lOo.OOo). in adanion to rh€ cosl olco,np.derion. d.na36 s prolidcd lot lh.
<br />5e 'cn
<br />10?6 ofrhc Lab.r ( ode.' ed Md ror*) \ l€
<br />DDCI.AIAIIOI
<br />I h6cby a,nm uodr pcmx, o apdjury that ! m licoscd und( prcvhion ofChr$s9(conm.ncins {ilhSdion 7000)oiDivision l
<br />of thc Busins and Prcf6ions Cod.. and ny li..@ i5 in tull aorc€ od cfld.
<br />(.c. \uhbc
<br />-
<br />< o"t,n tt, -3..,
<br />CAA$AIJCIIgILIIIDTIG.AGDNCI
<br />I hcEby affim undo p.nalry of tdjtrry rhd rhde is a coietudioa lcndinr as6cy ror $. pdfomEncc of thc sork lor *ti.h nris pdnil G
<br />issu.d(S6 1097. Civ C).
<br />l.e Je' " dd6s. _
<br />ATTI,ICAXLDECLAAAUO!
<br />I @y arEn unds p€nalry of ,ejury one of lne follosin8 dsldations:
<br />D.nnhion Psnrils-Asberos Norilication F.ddol R.gulatio.s ( rnt {0. Pano)
<br />-Requiled
<br />ldrd olNotifi cdio.
<br />t.di[ rhd rhe lcdda] rclulsno6 rccard'.8 6b6roe mmo\.1e. nJ /m'rcablc ro ths |nrd
<br />Itjkll-, r, 'n, r n,,. *,0 ,n6 apnl'c,rion dd ear. rh, lhc abolc inromtio. s codet I aAE ro comply vith all ciry and cou.ry
<br />Iordmn(6 d s'ar. L.*s r.l,rinS ro bu'ld'ne codrudrcn. od h6ebyau$ornc rcF€mhi!6 ofrtis city d co@ty lo drc nFo. fie
<br />abole morioncd prcnely for iEpr.rion
<br />{ppli.snl or Ag.nt SieMlu
<br />I'u'mite nnnr.ltrirtl: Y-
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<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 />Itrlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />,.. -.,,/FINAL Ubl/.4 -T;/'lvLr2) t-/
<br />Certificate of Occupancy LV UI
<br />Notes, Remarks, Etc.
<br />-.t
<br />//'6 -?ot{
<br />,,',,, lt'6'20tf
<br />4 R,J-*'Henfer tZ
<br />-,,>lrb')a8
<br />II
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