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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCAI{ATION
<br />I hcrct', lmfln undc! pcndry or l.+try rhd I 0n crc ryr rmrn rhc Conrlact E Liccn* b* ror rhc followins rca$n (Sc. 7{):l l 5
<br />Bu\nk\r a.d Profc*ion Codc): Any Ci!, or Counly which rcqutcs a llnnn ro .otr{ruc1. ohcr. nnpr'rc. dcn6li\h .r r|EL rny
<br />{d.rurc, nrior b ils hsurNe, lho rcquncs rhc allli r f{r \kh Fmir r. file! siSncd sl cmnr rhrr h.or shc h licc.scd ,rnnu l
<br />b rhc pmusbns of rhc Cotrtrcrols Liccnrd Lrw (ChuDIcr 9- Conrnf,tuiig wirh Sc.rion 7(lD ol l)ivi\bn :l ofih. Busin.( rnd
<br />Prolcsbtrscodc) or rhar hcorrhc i\cicmnr rhcrfrondn rhch \i\ ror rhc rllcgcd cxe.rflion Aoy vn,hrnnr orsccthn 70-ll 5hylny
<br />lDt'li.itrr lor a tcnnir suhjccrs rh. atrli.air ro n .ivil F.,lry or nor mrc rhu filc hlndrd dollas (S5u))
<br />L rs owncr or rhc lotIny. o!nrycnrloyccs wirhwrsc\ trs rh.ir q,k d,mpcnsrion, willdo llr sork 0.d rla iME n mr
<br />ic Ln oroficrcd ior sl€ (S( 7{144, au{ikssnnd thrarsions C(xlc: Tnc Connackn \ l-ic.nsc tjsdosnol olPlyroa.o*nfof
<br />Ihc pn)pdy wtx) builds or irrpr.\cs rh.cn ! who d.rs skh k)rL hin*clf or hcscll or rhmuAh hh or h.r own.mployccs.
<br />frovidcd rh r sdch i'npNwrrcN m mr inrcMcd d ofiarcd for $lc lI hoscvcr. rhc hiild rS or imnm$rmnr is sil *irhin oN,tir
<br />of conrDlction. rhc Owncr Blildcr sili hrlr rh. burdcn or ln,ving rhd hc or shc did Bn t{ikl .r irto! h. pmrny tor rhe Plqne or
<br />.-1. !sowncroirhcpopcdy- rn.rclu\ivclt.ontncrnu wnh li.ctrscd conrra.tmt,co {nd rhc |nojLtr (Scc 7(]'l'1.3u\ins\
<br />iid ftnr6\i)nCodcr Thc Cotrfocktr s l-i(ctrsc l.uw doc\ nol!,)d, t, ai otrncr.flropcrly*ho huilds or i'ntmvct rhctcon.
<br />r.rl Nho conrrcr for su.h tnojccrswilh0 (htrrrucronl liccrNcd numunnr h rhc co.rfrtr s Liccn\c ldw)
<br />I xf,.\rn,tn rnd.r Sc.ri0
<br />Dat. O*ne.
<br />w(lRxtiRs' (rlMPENsaTloN
<br />DECI.Af,AIION
<br />I hcrchyaflir undcr pcnahy ofFrjtryotu orrhc rolbqing du.l$'iuns:
<br />-lhrvcnBlwillnuinhinaCcnirl.ni.ofc.nsctrrtus.lilnsurcaorqoker'compcn\arn,n,rspn,vidcdlorbySc.rio.-17fi)ofrh.titxn Codc. f.r thc pcrformnce olthc aorl rn $hich rhc p.rntir n issucd.
<br />-l
<br />h0!c ond willmtrn rinworkcrq.o rtr.sdir insrrNc. rs rcquircd hy s.dn'n 1700 or rhc hhor ci)dc, &r rh. P.dohmn.c of
<br />rhc sork f{x{hichrhis pcnnil is issucd My workcr\' coflrNnsrn,n insurun.rcricr d O'licy nunrt}c.urcr
<br />Sfq+q- F;J
<br />-1b3o1JY
<br />-.*pr*,
<br />//'/^ /8'
<br />I ccnlfy rhar ir rhc |Erfornumc oflhc snk tur which rhi\ p.rnrir i: issucd. I \hnll nor cmnl,)y riy p.non i. any nranncr
<br />$ !\ ro bcco'm ubjrcr o ihc work$s ..nfcnsrrnnr hss olCalifornir- lnd asruc rhar if I dould tf,.oN $bJcd ro rh.
<br />$ortcn.onFn\arionprovisionsofS(ltun:lrIX)olriel-.horC&lc.l\hrll,fodhwthcondysirhrhokpRrvnion(
<br />WARNING: tnilDrc lo surc *orlcrs compcn$rion coturr!. i. unlaqtul. and rhnll subi.r ,n cnfl.)tt to (iDinal P.nnhi\ and
<br />.ivil hr\ xtr t) onc huNlrcd lhou\lnJ doll]rs I llr).(xrD, ,n rdd(i( b rhc ..sr ol co'npcn\rh. . da l.I!.\ rs t(nnlcd nJr rh.
<br />sr.rir)E 1076 orrri" rrEr Li{1c. idcrcn.trtrl.tr
<br />XIElrlIl Ua!
<br />I hcrcby lfitrr unds Fnahyorr.rjury rh.l I trD lienql und.r provision ofCh4rrc.9 (connmn.itr8 wilh Sccrion 7(xD) orDivhion l
<br />oi ihc Busincs ntu Prcfc$ionr Codc. dd ny liccns h in rull htrcmd criecr.
<br />/<:v",t,.5'1ff/
<br />CONEII!!:Ul)Nl,INDIllilliTNrr
<br />I lf,nby nfli nundcrFDrllyofpcrjuryrharrh.rnn.on(dcri'.lcNlin8.8cncylbtrtf,P.nnnmn..orrhcsorkfortrhichrhisFmlirir
<br />i\ucd lS( 1097.Ci C.).
<br />IIILIgdNLDIIIAAAIIA!
<br />I tErchy!finnundcr pcnrlryorpcrjury otrc olth. Iolr.wirS dcclorulions:
<br />Dcnnnniotr Pcflnns-Asbcstos Norifi.drn)n Fcdcrdl RcsuldlidN ('I irlc 40. Pfi 6)
<br />Rcquncd Ldtcr oi Nolifi .dion
<br />I..n'fylhi[hc icdctul rc8ullrions r-grdin8 r\hcno\rcfr)vdtc trot (Pllicablc r) rhi\ pn+d
<br />-l
<br />ccnili rhd I h,vc rcad rhk.mli.dn,n,nd {rrc thll lhc ot{vc inn,nurion is.ormr. I.!rc to conllly wnh all Ciryand Counr,
<br />o'Ji'rn..\ xn(l Srrre I-r*\ rl-iinS I ildi.x con$rudn,r, ond h.rchy aultx,nzc rcrrcscntativcs ofrth Cily md Counr! ro cntcr upotr rhc
<br />rlrtrc nrdidrd pr.Fny i, t,?-/3-)tr7."..- ^(1 t.-*t ... ,
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq q\r.\tl I W(D
<br />lnsulation/Enerqy
<br />Drywall
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL \\r\<$'hrn
<br />Certilicate of Occupancy ,
<br />Notes, Remarks, Etc.
<br />0
<br />f,
<br />Ext./lnt. Lath
<br />Brown Coal
<br />i l'lo
<br />I
<br />? ltt//
<br />w,",9'/3'/E'
<br />tt
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