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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS O\ NER BUII,DER DELCARATION
<br />I hs.by aflim undq pdalty of nrjury $a! I @ .rcnp 6om rh. Conlracto6 l-icense l,as for rh. follosing r.Mn (3(.7011.5
<br />A6in6s dd Prof6si6n Codc): Any City or Counry trhicn rcaut6 a p€rni to enntud. altd, inpror., &nolish or Epat dy
<br />srtucr@. pior ro irs isumc€, alr. r.quirs lh€ applicst lor such pcmir ro fiI. a si8n.d $atmml lhol he or she B li.d.{ pcuaJtl
<br />lo rhc Fovi.ionr ol rh. Co"lraclois Li.enscd Low (Cisp'd 9, Commcncins wilh S*rion 7000 of Division :l oalhc Bus'n.ss dd
<br />Pmfsions Cod.) or lhar hc or sh€ is €rcopr rh6€thn &d rhc bsis lor $. .ll.B.n .xmprion. Any ri.lation of Sari.n ?01 I 5 b! tny
<br />applic l for a p.mn subj(t tl. rppli.mr to a civil p6ahy oi.or ,nor.lha five hundr.d dollss ($t00)
<br />5f;*- .nn. *.*r. or my ehploye sirh rvas6 s r hcir $1. .o,npssrion. will do rhc rvort dld rhc srelE 6 mr
<br />inrfl&l or o,Icr€d lor el. 1Sd.7044, Busin6 dd Pn'l6iom Codc Thc Co.tacrors Li.d{c tn$ d.a nor apply to o o*n( ol
<br />rh. poFny who hrilds or imrovGlhr@r ddsho do6such \rc hihself or h6cllor lhoush his or hd own mployc.
<br />provid.d thar such imForffiB e not i dded Gofi4d torsl€.1[ hory66, tc boilding or impmvmdl is sld q'nhin on. tu
<br />otcomplerion. thc O,n.r auiBs will hav. rh. hrdft oltioving ta h. or sh. did not boild or imp.ove lhe p(p6t, aor rh. Pu'Foe of
<br />l. d owns o I thc prop6ry, d crclusiv.ly co.ta.ring lvnh licmsd conlmroE ro co6lruc1 lh. I'.jd (se 7 t, Ausins
<br />and ft!ftssion ( od. rhcCotrrracl.r's l,icms€ ljs do6nollpplyh do(nd Drpiop.nr\io buildtori'npr.vs rhsmn.
<br />and trho contracrs lor such [roj4t virh a co.ta.'o(, licmcd pu suer h lhe conra.d s l.i.e6. h\!)
<br />unds Sdioa-- B. & P c
<br />"".",11'20- ?dJg
<br />I hqeby amfln und6 pe!flhy or pejury o.e of rhe aollo{ins d..lararioB
<br />I hav. ed Nill nai.tai, a Ccninc.r. o I cotuor to sela-lcur. lor $orker conDen$rion, d rrorid.d lor b, S(tion 3 700 oilh.
<br />l,hor Cod.. aor lhc p.rlom crof Ih.uort for*hich th.p@n is i.!!.d
<br />Ihav€andwillna,nh,nwo ers .onpeBarion is!r.n.c. s requt.d by Sct on 3 700 ol rhc tibor (nd.. lor lhe psfom ccoI
<br />the Nort tur which rhis p.nni is iie.n My {ort.rs comp€.sarion insurmce cari6 and Poli., nu,nba tre
<br />PolicyNumb6r-E$ir6
<br />1S-.c,1'6 rhar . rh. pnaom&r.orrlr n'orl tor shrch rhis psnir is issucd, I shallnor.mrlo, any p€son in dy nend
<br />$ ri! ro b.(,m. subrd ro rhc worL6' (ompsauon la*s ofcalifomia. Md asE th0l ill should b.come subjat to llE
<br />{orlLrs'compmalionprcvisionsofSdio 1700olrh. t.ab.r Cod.,I shall.lonh$ilh comply *nh lhd* porisiom
<br />NARNINC: r.ihrc ro sur€ s.rkql omposrion covgasc is unlarrul, Md drll subiar an o.plo)€r lo rnniml p.n lri6 and
<br />.ivil fincs up to onc hundren lhousod dollss ($100,000
<br />sLlion 1076 oarhc ljbor Codc. inls61 ed riiomey's f6
<br />st olcomFNorion, dina,scs s provided fo! the
<br />I hseby amrm unds poallyofrEjury Ual I an lic..sd u.de l'o\ ision oachapt6 9 (.onmo.ins wnh sdion 7000) oIDivisrcn l
<br />ol
<br />'lE
<br />Bosi.6 md Pbl6ioN Codc. d By lic€N is rn irll lor. dld efid
<br />co.NualcullN.lrNDlN(ilcl,lcI
<br />I h6cby fl,Im undr Fnalry of pojury rhd thd. i. t codtudion lddinB asocy for lhc pafommce of th. \rork for Nhich fiL pdmil is
<br />issu.d(sd 1097.civ c ).
<br />AIIII(AILDICLAsAIIAX
<br />I h6*y ailm unds p6ahy ol p€rjury on. ol rh. aollo*i.s d-l-rt ions
<br />D.nDhion Pdnits-Asb6tos Notification l-.d@l RcsuLrions iTirlc 40, Pd16)
<br />_R€qun d Lard ol Notificalion
<br />I cdiay thar the aedsal r€rulatioN esardiry 6b.skx r.hoval dc .or arplicablc to lht projNr.a-<-21 (+
<br />'E lha I har c rcad r his ,pplnarion dd iarc rhar thc abolc infomation i! c@er I agrd to conply wilh all Cny and Coudry
<br />ord'na.c6and Sr .Irssrl.ringro blildin8 aulhoE. r.F.srdils of lhisCity d Couoly lo drd rp.h fi.
<br />abovcn€nrionedDropeny lo, i6p<r n purros
<br />11- 22'2",/ UApplicatrl or \Aut SiBnsl'nc €/+2-
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Fram inq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />I
<br />FINAL // /z///7 ,.&y'/.
<br />Certificate of Occupancy 7-\-v
<br />Notes, Remarks, Etc
<br />-+
<br />o,,", l(- >c>-l1^
<br />L.nds s Nrmc
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