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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNEf, BUTLDER DELCARATION
<br />I hc,.by utlirnr undcr l,cnolly oI Frjury rhal I d .kmpl rion rhc conl,scio$ Liccns. l)w r(tr rhc rorhwiry E8$n (sN 7011.5
<br />Businc$ aril Profcssion Codc): Any Cily or Counly which tcluircs a pcrmn ro $nsrucr. altcr. inlPmvc. dcmri\h or Eron rnv
<br />sdcrurq rn)t k, ns hsuaftc. .ho rcqunc\ rhc {p,}ltanr l'or su.h lrrmn r. ilc r siSncd shlcmnl rhd hc or sh. t li.ctrtd plruonr
<br />r. rhc pmvisions ofth. G,nta.ktrt Liccnsd tir (Ch!flcr 9- Conrmen.inB wirh Scclion ?uD of Divtion :l .r $c ausinc$ ond
<br />Pofc$io.s Cod.) or rhnr hcorshc tcrem ficeftonandrht bask ror rh. altscdcxcnPri.n Aiy vntrlionofs€liotr?{)ll 5l,yaiy
<br />. 0mhcrnrrhrrncrmrr\ul"J.(r.rh altnl,cJrr ro rctrrlNrrlryor r rrrc rh,n rtrc huiJn'ldollJ'\r'lr or.
<br />1 0 1,' ,'" ".,,,r,* o.""y. n, ml cmrrrn)cc\ r h *!BDsxs rhct srd comrcnsorion. *illd(, rhc w.* 0'ld rhc imrurc h Rn
<br />04 cnacd m n rcE l lo! {h i Scr ?0.14 Bulnr( J d Pmrcssion( Codc Thc Conlts.roi s Licus Law docs not lnlly h xn .*mr iir
<br />rhcptuFny *lt, hikls or nnFturcs lhcNn. and who des $ch Md( hinr\.lr.r h.r$llor rlu.ush hi\ or hcr o*tr.nlloyccs-
<br />providcd rhlr such impmrcmnls ar mr inrcndcd oroffercd forsk.ll h(,Rcvcr, lh. huiklinE ot impmrcftd k bkl qilhi.onc rd
<br />oIo,q,lcrion. r'lcOmr 8ui)dq $illhf,( rhcbonlcnoftbving rld hcorsh.dil , huih or in{,mrc thc pqtny for rhc rlrlr* or
<br />-l.
<br />rs owncr oi llE prDcnt. rncr.lunlclyconiracrirg wirh liccnscd conrrut,R r, ..nnrud lhc Pmjcr rsc. T(}14 Buqncs\
<br />iM lt lbsin ('.dc Thc CoDtnclols Liccnrc l-aw dacs nor apply b n o$ n$ ol proFny who bu ikh or nnprots rhc.con-
<br />aa{l who codlacr for such pnrccc wirh ! Conhrbn, li.cn\cd ,utrua rorh.Conidcroir l-iccnsc tje)
<br />-l
<br />rmcrrDnr undcr Sccto0 .11 &f( lnrr[nrcnlr]
<br />/^,",9 31y ,ry*
<br />Dt.( t,lt{,\ I t(rN
<br />I hc'clry rilinr und$ rcnilrv.t Eriu.yonc ofrhc nnlosin! d..hrxrnnr
<br />I hrv. mdwill minroin iCcnilEarc.fCon\cnl b Sclaln\u'. n)r wor kcs' conFcosal ion- 0s pmvidcd fd hySccrionlT0Oolrhc
<br />I ibor Codc. lor I hc pcrto@n.c .l rh. sork r'or rnich rhc Frnril is issuql
<br />Ih"!crdwillmi'nriisorkcriconrpcnsrrionin\umE..rsrcqoncdhySNriur:l?0(rotrhcl-ah,rGdd.fotthcPoli)rnu'nccol
<br />rhc work for *hi.h rhis pcmir is hsucd. M!wortcA co'npcnsrri{rn insrh0.c.rnicr rftllx,lic, numb$dc
<br />Policy NuniE!
<br />-Eroircr:
<br />w ccniiyrhar in rhel.rf.rman.col rhc work lor shich rhi\ pcflnil ir i\ cd.l shnlltrol cnrploynnt P.non i ant minDcr
<br />su lirom suhrcct to thc wor*cs co'npcnsdn,n hw! olCrlifornid. Md lercc thol if I should ttconr subl$r to thc
<br />wo*cr{ onllrcnqriotr lrovhion\ .l sc.rio. :17ff) of ihc Lh, codc. I shrll. i)nhr irh co.ll)ly wirh rlr)* lrovisions
<br />$ARNING Fuilure b $.urc qorrcr .!m|En\(tr covcnsc i\ unlrRru!. rid shirl suhicr arr cmPloyer t, siinirrl F*Drlric\ tnd
<br />civil liors uI k, oru huidr.'l rhou{.nd d.llnn (!100.00)). in ltdiii(,n ro rhc.o$ ofconrPcn$ri{,n. drnrFcs rs Providcd lor rh.
<br />Sccrim.1076.rrhc ltrhn Codc. i crc{rndr onryi ti..
<br />w,.s- \-/ r
<br />rlt.( I \R\rl()\
<br />I hcEhy riltm undcr pcnalryor,.rjury rhd I om liccnsn undcr rovision orCh.t'rci 9(co.nEmins wirh Scdn,n 70(x)) ofDivision:l
<br />of rhc Busin.ssand PofcssionsCodc. dd nryli..n\c ir in rull lns md clltcr
<br />Liccnsc Nrn$.r
<br />-
<br />Corl.{clo.:
<br />CONSTRUC'I'ION LFNN!N{i A(iENCY
<br />I hcdhydmr u,rdn r.n.llyolpcrjuryrhtrr rh.E n a.o.d crbn lc.dinS a8ctrcy ror ihc Pcnormm..lthc wotk itr*hi.hrhn Pcnnil h
<br />hsucd (Sec. 1097. Civ c.)
<br />kndcr'!Na,E:-
<br />APIIII]ANIDECIAAA.I]ON
<br />I lElt y lrm !od( penalry br p.rjury onc ollhc folb*n!8 declmrions:
<br />Dcmlilion Pcrmirs'AslEsros Norin ation Frdc.alR.Bularions (Tille 40- Pan6)
<br />-Rcquircd
<br />Lcucr nr Nor'rf, drhn
<br />_l!.d,lJrhdrhcl.d.mlrcguhonnsreF{dinpJrhc{nUcm,.lrtno'0n cahk ro rhi. n",Jnr
<br />trLt.dnv tut tta\c tcsd thN JnrlKar'. rnd {ir. rharrh. abovc intorrorion is.od.cr IsErNroomPl,w h arr cny snd cou.rv
<br />E,lri6nines;trd Srlrc L!w\ rclarrry to bx,ldre .onsru.hotr o hcrc6y ollhorizc eprsenrttiv.s otlhh City ond Co$ryio cnrs u,lon ltr
<br />rh^c nrnr,trrd t),nN:r\
<br />rlppri.,,r "" aB",r si,:n,ru*
<br />$n*,u." *-.,,.u,,,+b 44
<br />.*s--/z
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Rool Sheathinq
<br />Shear Wall I
<br />Framino t8 ,.y-*
<br />lnsu lation/Energy
<br />Drywall
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL K77-1
<br />Certilicate of Occupancy
<br />Notes, Remarks, Etc.
<br />UFER Ground
<br />Subf loor/Vent/l nsu lation
<br />Ext./lnt. Lath
<br />/b-t
<br />L1.Jc''\ AJ,lr.. _
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<br />lStzcl
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