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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE IDiSIG.COMMENTS OWNER BUII,DER DEI-CAI'A'TION
<br />I hcaby omrm u.dq tcnrlry ol pcrjury lhar I !m cxcmnr rm rhc Conrru.rra Licens hw tor itu l.lbsirg rcnson (Scc 70:ll 5
<br />Busincss ad Prolcssion Cnlc) Any Ciry or Otutrt) which rcquiEs a IInn, ro consrrucl- ali6. inlplovc. dcrreli\h o. Ef'an n.y '
<br />situcrlrc. pritrb i( ilsurtr.c. rlm rcquircslhc applic r for ru.h lEflnit lo fiL r sisRd {arcrftfll rhar hc.r sh. is lic€nsl Pusua
<br />b rhi- nmvkions oflhe Conrlck \ Licctrscd Lrw (Chrllcr 9. C.mrcrnrg with Scclion 7000 ol Division 3.rrhr Buiin's rnd
<br />Profc$n,ns Codc) or rhar lf,orsh. is crcmDt Ihcrclioma.d thc l,ast ror thcullc8cdcxemPrion. Any viol'lionolS..rion?011.5 nv anv
<br />rpplicam ror r r.nnir subjeh lhe applicnnr ro a.ivilr.trrhyolnol m.rcrhan llv. hundrcJdolles (S50ol
<br />-1.$owncrofrhcpmpcny.ormycnlloyecswirhwrgcsasrhcnsbconrcnsati{)i.willdorh.workandrlt{lfl.tumknorn. cJ orofcrcdiorslc(SN7014,BusinsaandPiofcslonsCodc'lhcConk,.i.rsLicctr*L,wdoc\nor0ptlvrornowncr.t
<br />rhe pR,lcny who b ilds or inym(s rhcNn. sri *ln) dm\ \eh aofi h mscll .r hcr€ll or rhtuu3h hh or hcr n*n cmpl.vccs.
<br />Drcvidcd rh.t su.h imporcmnh m mr inrc.dcd or o0arci ior sslc. li hdnctlr, rhc boilding or impfuRnEnl is s,ld *irh'n onc vt-
<br />oi.ooDLrion, td owncr B ildcr will hrlc rhc burdcnotlxJvirre rh tE or shc dil nor build or ir{rovc lhc tn,poiy ror rh€ puq{e of
<br />-1.
<br />is .slcr or rhc Impsry, am cr.lusivcly conhd i'rg si h licrtrkd ..nt doF Io connrucr rlE tmic.r (Sc. 7ll,1 B sim\\
<br />ud tbrcs$n C.dr ThcConrracrois l-iccn\c l-rw docs nor ltPlyro onosnforli(,ttr ysho huilth.rinrtmves rhctcon.
<br />rtrd sho o rucrs lor such prcj.{G wirh 0 C. r0cto(9liccn*d flrru.r h lhc Conl,rftn\ l-i..nsc L1w)
<br />Dr!! a -!!]n
<br />I hcrchy ailirm undcr p.nanyol p..iuryorE ollhc li,ll,,si',3 Jelrturi.ns
<br />-l
<br />harc ad vill @intuin 0 Ccrliararc oi Conrnl k, scli ln\uE ror sorkcli comncn\ar t . as pmvidcd to, l,v ser ion r?0o of lhc
<br />htxtr Cc{c- lor lh. pcrlorndc ot lhc work for whtn I hc ll.rmi h nsu.d
<br />-lhrlc
<br />a will uirnrin w.rkcr'conrpcn\ario, insurrnce- trs r.qutr.d bySccrn,n:17(X)olihc Lnl$rCodc. nrrhcl.rloan0Ncol
<br />rhc work ror$hichrhis p,flnir is issucd. Mt*orkcn ronrr.n\rtn'n itrsurrncc.rricr d Flicy.umhcr 8:
<br />Crtrirr
<br />-l
<br />ccnily lhar ii rhe Frnn.!trrc orrlt wor* lor *hicn rhi\ plrmir h issucd. I shillnor.mlloy lny n 6on in inv f,snr.r
<br />s, nsh bc.om \ubicct tothcworteB compcnslri{ lrss ol Crlii Tir. ud lgrcc rh, if l should trronrc uhFd h ihc
<br />Nolrctr.D'nFnsaliotrDn'visionsoiSccri(r:lT0Oorrhctjb.rCodc.lsttrll-lonhqiih.orPlyqnnrin'Epnviriotrs
<br />wARNING: Fnihrc ro scurc sorlch (nnp.ns i.n covcrr8c is unla{lul, dd shlll sib,ccl a. dlrn,rtr k' dinrinal Fmlrtcs !toj
<br />.ivil 6ncs up t. otrc hundrcd rtx,r\,ftd dollaA {$ltD.UD), in .ddition
<br />'hc
<br />os olr:yns'ion. danuscs trs lrovidcd.o Ine
<br />:::Y"7d:
<br />I hceby.innutrdcr pcoalryofrErruryrhd I a li.ctr*{ utrdcr Pmvision or ( hxprcr 9 (.oDntrmins wiih sdior ?No) or Dilili(rn l
<br />rr rh. Btr\i',.\\, Pnf.(io.sCod.. r 'n! liccn{ il iD tutl l.rcc and cltccr
<br />CT)NSTRI]CI-!ON LFITDIN(i A(iFNCY
<br />I hcrcby rlfirn !trd.r F.alry ol lcrjury rhd lhcrc is a consleri,n lcnding s8cnc, ior rhc Frlotturc of lhc sork fItr whi.h this lEmil ir
<br />is\ucd (Scc.loi)7. Civ. C.)
<br />ATTUCANTIIECLANAIIO!
<br />I h.Niy dllnn u n,ls !.nalry ol l.lJury orc ol rhc follo*i!8 d(lf,ri ionu
<br />DciDlirion Pci,nits Asbcsror Norifi.riion Fcdcnl Rc8ul0rions 11irlc.r0. Pad6)
<br />-Rqlircd
<br />Lclr{of Nori[.dio.
<br />I .dify rhlr rh. fcdclo| rcSllul io.\ rcgddi.g *hnos rcmovll ote nol atrplic$lc ro rhis proFcl
<br />I ccnifyrhor lh!!e reld rhis aDpli.alnrn nnd stolc lhnl l,E lhovc inlomdion is conecl lo8xerod,f I, t \rirlr r I Cir)_ xtr(l (ir
<br />r_(-i) trtrd (-! ,ryki.nr.r olltr]rhcor'lir!ftcslndSrlrcLlwsrc[iringrobuildin3cotr iotr mJ lggryauhftn. .c!rcsenhr i!$ or I his
<br />rh,vc mnrioftd pn'Nny lhr iNor{rion
<br />ADDlionl o. /\ecnl Sigtroturr x ?/tA
<br />Set Backs
<br />Forms/Steel/Holdowns d-ttt>*-l;ir.
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsu lation
<br />Roof Sheathinq g/w-/u) )
<br />Shear Wall /,t 6u,oral /. f\-
<br />Framing f-r"'rlo "b-/e_
<br />lnsulation/Enerqy qr'?rrltb-/- K\-
<br />Drywall 77brh-'r>--
<br />Ext./lnt. Lath Ar<Er*-1cz-
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />A
<br />FINAL w-1"tlr k,W.vl
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc
<br />Flood Zone Certif .
<br />L i.c.s. Cl, ss:
<br />-L
<br />iccnsc Nlnb.rr
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<br />D.re_ Cotrltrlor
<br />bnJcr'. Addrcs
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