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BUILDING- INSPECTOR RECORD
<br />COMMENTSSITE-WORK DATE tD/stG.
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation
<br />Roof Sheathino
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />'- tv 9ttzt)Drywall ?-?P -/o E rl ta.
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />P ln/.l'lo-t?-te 61a tti
<br />Handicap Req
<br />Deputy Final Repon
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />@FINAL/-/q-//,
<br />Certif icate of Occupancy
<br />Notes, Remarks, Etc.
<br />owNER tlt ILDI)R l)l:L(,\R,\ll()N
<br />I hcrcby afltn untlcr pcnalry .r p.aury Ihil I m excmrr from rhc Cr,nt&ror' Lice.\e liw ror rhc rollowins rcren (sd 70.11 5
<br />Burinc$ lnd Pn,rcssion Cudc): Any Cn, or Couory whi.h icquircs I [Emit ro dJnsdcr. rllcr. im[ov.. dcnx,lish or EPan atrv
<br />itucrxrc, rrio. to irs hsuarcc. lls rcquirc\ rhcapplicmr for suchremrir k, fi|. a \i8md srotcmnr rhnr hcorsh. licentd purslanr
<br />ro rhc oovni.n\ of $. Conrhclols Liccnscd l,w (Chanr.r 9. Cdnnncncing wirh s..rion 7m0 ol Divisio! I or lh. linsi'rcs rnd
<br />Pror.r\ions cbdc) or$at hco,shc iscxcrpr rhcrcrior,trd rhc brsn tor rhc dlcgcd.rcnuio. Anyliolario.ofSccrionT0.ll5bvrnv
<br />applicnn fo. !Frmir \!bjecr\rhc aptlicaDlroacivil!€nalryofnotnoorhanfi\thundrcddolles($5m)
<br />-1,
<br />!* owncr of lhc trcFny. o,mrcnrLrcc\ wirh wagcs N rl[n et s,mlEn.arion, rilldo ltr rorl aod rh. sMN is mr
<br />inrctulcd or orcrcd for slc lss 7{N4, arsin ss and Pnfcssions Cqlc: Ihc Co lncn,\ Licctrsc ti* do.t nol ,pJ,lv ro a owicror
<br />rfu pmreny who bxilds or impro!.s rhoEnuJd slt) dftr lmh wo* himscllor hc^clfor rhbugh his or h.. own.ntpk,yccs.
<br />F)vided rhrr su.h inlpowtrEnr N mt inrcn& or ofiercd ,or slc ll hosc\q. rh. hoilding or in{,n *m is sld wirhin o.c F{
<br />ol on{krion. rlE Owner Buikrd will h,vc dr burdcn of provinB rhar hc or shc did mr tuild or inttuk l}r pmlcnv tor rh. rulr,* or
<br />-t.
<br />aro{nc'orlh.rropcny, urcxchsivcly.ontacri|8 wirh li.cDscd conrracr. id ..nsrfl.r rtr rmjd (Scc 7(}44. surincs
<br />ind PiDlssiotr Codc lhcG,nrr,crof\ Liccnrc LoR dcs nol amlt ro ,n ornfi ol Properl y *h. l'lilds or inr[ovcs rhetco..
<br />anrl *h. co.t,.rs ror such pmrcch wio a G,irtuct,(s) liccnscd pu6uam t'rh.Conr0crors Liccnsc l,aw)
<br />t ad .x.nDr undcr Scdiotr-, B. & P.a tu lhi\ .caso.
<br />Dar.: O$ner:
<br />wonxr. ls' corurom,rrrlrr.i
<br />DD!:I/AA.rIQ!
<br />I hcrcby,fi'r und.r pcMltyolpcrjury.ft orrhc rollowin8 d(larutions:
<br />I htrvc lNill nEinrain 0 Cenificare of Co.{nr bsclaln\uE f wor*c6 conD.trsrlnr
<br />ljtxtr Cod., a{r rh. p.rfoflrukc of rhc Norh tor shkh rh. ,).anir i( ksued
<br />.s lrcvtlcd lnr bySc.ri.n llrD olrhc
<br />I hrv. rtrd sillnui rinsorkcis.onlcn\lrioninsuramc.a\rcqundh,Sccrio37(DotrhcLllx,Corlc.tbrlhcp'rrnrnn " r
<br />rhc work for whih rhisF,rnir is issuin. Mt wor*cn conrrns.lion in{ran...rin !iFlicynuarhti rcl
<br />PolicyNumhcr:-
<br />I r.nifyrhd nr rhcDcriinnarccofrheworkf.r whi.hrhis pclrnil t hsucd,I shrll not cnploylny Pcr\otr in rnyoMnncr
<br />e $ ro bccom suhicr tr rhc sorkds .ompcnsatiotr lo*r ofCalinrtria. Md agrcc th(t ill should ttt.m subisl ro lhc
<br />wollcH.onrFnsarionrrFvisi{,isolsccriotrlT0OolltcLjhorCodc.tsErll.fiinhn'ilhconrlywirhrhosl]()lkions
<br />WARNIN(;: Failurc ro sc.urc sorkcr cor.pcns ion colcrsc is unlNlul. and nlall subj..r rrl cmlloycr lo cnn n,l Fnrlties nnd
<br />civil 6trcs xp ro on. huturcd thouslnd d,lLn lsl0o.mo), in ndd ion hrhccos of.onU.nsalion. drnuges rr rr.vkl.d fi' thc
<br />Scrrnn' llrT()of rh. l.rhr (itrl.. inrdrrn rd onrrr_': l.c\A,n?/tr/t 8 n,l,*',uL4 4/r,r ft^sFrr,rra(NTR^c I u R' bf,cr aRATloN
<br />I hcrciy arfinn ond.r l)cnrlly oapcrjury rhar I am li.Tn{d uidct pn,vision oiChlprt! 9 (.ommNin8 uith Sccri.,n 7o(x}) 'rDivi\ion:1of lhc Busincs\ rnd Pn,r.ssn,6s codc..tul myliccnsc ix in lull rorcc dkl c[c.r
<br />,6
<br />?1rr//4 "(
<br />I hcnhy a,Itr undcr pcMlr, ot ncrjury lh0l thcrc t a .onsIrucrion lcodir8 {.ncy lbr the Ilcrlbrmn.. or rhc work ii'r $hich lhk Frnil is
<br />hsu.d (sc. 3g)7. civ. c.)
<br />If,nJ1 . Nrnr
<br />-
<br />AIILTEANLI}ECIABAIION
<br />IlmbyJiinnndcrpcn0lryoipcrjtrryoic orrhc r lk,wins dcclIarions:
<br />D.ndir,on P$.nb'Asb.no\ Norincarion F.dc.rl RcSulationr (.l nt 40. Pan6l
<br />Rcquircd t ttcrolNolificari{nr
<br />-l
<br />ccnilythlr rhca.d.raln8nlrlions rcs{dins ushcno! rcmrvrl n nol sPtlicrbk k, rhn Pnt.r'
<br />-l
<br />ccnify rhd I hrvc rc.d thk applicarion dxl ddrc rhar thc.h.vc ini{rnrarion iscotur. I d8rc ro.onDly sirh all Cirvand Counlv
<br />ordintrn cs nnd Srarc ljws rchring to buildins .o.erucrn,n. md hcrchy suthorizd rcprcsnt ivcsoflhirCiryrtulCoutrryloenreruB,nin
<br />atx)!. enrtu d porcdy for irstEcrim purlxNc\
<br />Appt rnt o, ttt"nrSt*n tun i{@a,
<br />Prmile mme tprinlr: /
<br />6/'filY
<br />eil\-- ,"" 4/ry'te
<br />xoe--tt:xftbE//
<br />Erection Pads
<br />T-Bar
<br />s3L8? f
<br />tt
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