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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNI]TI BUILDIIR DELCARATION
<br />I hrrcby,mnn undcr pcnalty ol pcrjtry rhar I dn.rc.r!, titrn rhc ConrB.tn t.i.ctr* Liw hrlhc n,ih*ing rcn{ (Scc.,0ll1:i
<br />Brsirc$ od Prolt$ion C(nle): Any Ciry or County vhich rcquncs ! pcnnir to .otrnrucl- llrcr nnpi{,vc dcnDlilh or rcPin MJ
<br />ilru.lurc. priorh ic i\x r... .1$ rcaun$ thc apd n! l'or\trchp.n h ljlc a si3rcd darc'ft.r rh,r h.or sh. h li.ci*d N.sua
<br />h rhe lovi\iotrs oi thc Conrmcttr s l-i..ntd tjw (Chrnlcr 9. Conrme.ci.C *irh Sc.lion ?(Xx) of DivNion 3 ofrhc Busin.ss and-
<br />Prci.ssirr\ Cotlc) or rhd h.orshc ncxcnrrlllErcliorand rhc br\n rti lhc lcEL{cxctr1Prnni tryvir)]llion.lS.dn ,0rl5hv,nv
<br />rnt,licrirfr, rFnnir subjcch rhc lppli.ahr h a.i!ilpcn.llrolnot mncrtui ljvc hundrcd dollan (S5l$J
<br />l. * owncr or lhc prcFrly, or my c 1llort*s wirn *ngcs is thcn sb cotltis,riotr. will do lhc w.rk lnd rhc slMrurc is n,
<br />i' .n1dl or oficrcd lbr slc r Sa. 7Ol4. Businc$ and holesrions Cod. Th. Co actoi\ Lic.n* Law docs not lnplv ro m oPmr of
<br />rh.I,n)Fny wh. huilds or inlami$ lhcE)o. a.d who docs such so( himsclror ho*lror rhrcu8h hk or hcr own cmPloyces
<br />nrolidcd rhar such inuroktuns m tur ii .Blci or ollcEal l',)r srlc lt hrwcvcr. rh. huildiDg or i,rPDhnEnr is sU wnhin x'r ,tr
<br />ofonpbdm. dx Ownq Builicr will tu\t rhc bordctr ol foviry thJl lE or shc did mr ttrild or it{,mrt lnc lsFnv lor lhc l[qx,* of
<br />-l-
<br />as owrer of lhc pn,pcny. ,n cxclusivcly conl&crirrs *irh lice.sdl .offidoF to con{tu.r rh. pmi\r (S(. TOrt Baik(
<br />rnd Pnf*rion Codc: Thc Conilackn s Lic.nsc L.w docs nol.nnly b 0n osncr olpropcrty sho h!ilds ur inprovcs lncrcon.
<br />ond who o.!crsfor\u.hpmjca:rs*ith!Coor,a.lo(s)li.tn*iPuruarllorhcConhcr.rsLiia$LI*)
<br />lrNc\ctrrpruxl.rsccriinr
<br />-.ll&l'Cturrhi\rcrnrDlt€ orrer
<br />lV( lRKrRv C()l!I PFNSA TION
<br />U:CLANAIIO!
<br />t h.lchy rlfinn tndcr l..,lry of Pcrjury onc otrhe follo{ios dc.lerrio.s:
<br />I havc xnd will roinrsin , C.nirhiic of Conscnr h Scltr lnslt tur wor*cF compcnsarion. a\ Povilcd for bv S*.-rion 17m ol Ih.
<br />lrln cMc. for lhc rErr'orrone of rhc wo.* for rhich thc ncinlil n i$!cd.
<br />I hav. and will nrinrair worksr conrr. \rr io. Nu.rrEc. !r icqutcd h' S*r nr l7U) ol thc fnbor Codc. for lhc pc 6@nc. of
<br />rhc work r which rhis Frmil is is\ucn M, *.iklal onPlnsrt ion iNut,n.c .iri$ 8,ld lolicy numb.r n:
<br />I.edifyrhar inlhc pcraorMi..orrhc qolk iot whichrhi\Pclnin is nsucd. r shall nol cnflt,y rtry rcnotr inanvman,rr
<br />$ a\ t, r{.onr subrr lo lhc worteE .on!*n\arior hws orcrlilbtnnr. m/ +rc. rhnl irI should hcconE tubjccl ro ttF
<br />sork$J .omp.ns,rioo !rclisions of Scciidr l?0o ol rhc tjhtr Codc. t sh,ll. r('n hsith comfly $irh rh,{ povsn,n\.
<br />WARNINC: Fdilurc ni scur. uorkcr' comp.n\arion c.\t.J8c is Dtrhwlul, od shull sublc.r r. coun )€r b dnrinll Fnalrics and
<br />.iril [,rs uf r, r c hutrrlrd lhou\rnJ dol]rrt iil(X)
<br />Sd.ri{", 1o76 ofrlr lnlrtr(i\!c. inr.r.{ JtrJ rr!n'ry \
<br />7- rz ' >o,z
<br />Ill!r=!]t!ua!
<br />I hcrchyomfln!ndc!!.nahyolperlurylhar Iam liensd undcr rorisi.n of ChnPler I (comm in8 wilh Sccrio. T(xx)) ot Divhion ]
<br />or thc Businc$ and Pofcssions Codc. urd nly lic.ne is itr tull t rce ard.ffucr
<br />f - t2-- 2o rfu
<br />()NStRL(',rl()N I ll\DlN(; A(;LlCl
<br />I hcrcby lmm undcr FnNx, ol pcdury l,El rhce n a .ondn.rirn lcndins .scrcy rd rhc Frfornrmc of rhc w..k for $hict rhh Fmn ir
<br />ksucd lsa. 1097, civ. c.)
<br />AEIUC NLDECLAI{IION
<br />I lrcEr,y ullro und.r p.n.hy oirc+ry orc or rhc rolk,wi.8 dNlaratioNl
<br />Dcmhhn Pcrnir\ Asbc\r6s Norificltio. lcdcnl Rcsulsri,,nl (Tnh {0, P!n6)
<br />-RcquiEd
<br />Lf, n.rof Nolifi .alion
<br />l.c nyrhrrrhclcdcralresuhri(,ns rc8 dirs$hcnosrcnrHltrrcnornPPIrfilck,rhi\Iroiccr
<br />_l ccdifyrhar I hrrc rcnd rhisimlir ,ni,n, rn,lnar. rl'xrrlr rlxrc ifl.nnr(i{nr kcorc.r I aFe ro L_ompl, wirh nllciryand counrl
<br />!rLliirr.N ftls1xrr l.r1virlxr ia ro htrr lrhk Cir] rnd Counry h ctrrtr uFrlhc
<br />rhrc Nnriorcd pmpcny nn i',
<br />,\prlirnnl o./\gonr Sirnrr
<br />LtegKqt-{e
<br />7- tz- bt 12
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation v a)
<br />Roof Sheathinq 4 q K'l,u es^x?*{:'ry
<br />Shear Wall
<br />Framino
<br />lnsulation/Energy
<br />Drywall
<br />Brown Coat
<br />It/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Fleq
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certil
<br />FINAL a a/n+lb /o-
<br />Certificate ot Occupancv r
<br />Notes, Remarks, Etc
<br />l.i.cn\c Clx\s:-l-i(cnsc Nun,tir
<br />Ext./lnt. Lath
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