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BUILDING- INSPECTOR RECORD
<br />o\vNt:R aL:ILDUR DEl.( AR.\'l l()N
<br />I hseby.mrn undd pmalry ot peDury lhar I dn.xmP from thc Contractou L,cehs liw for lh.lollowins r@n (S(70115
<br />Busin6s Md Proasion Cod.l any ( nt or Counly $hich r.quir6 a p6nril lo onsrtud. ahd. inprovc d.inolish o cDat rnt
<br />srtucrr., pflor lo irs issudcc also rcqut6 lhe lpplicdl lor such Fnni b fil€ a sisied slsrmd lhll h. or sh. is li.tued DNud
<br />ro rh€ Forisio6 ollhc Conra{loas Li.cnsd Law (Chags I, Cohicnci.S wilh S.dion 7000 of Division 3 oarh' susin's dd'
<br />Pm fsions Cod€) or thll hc or sh. is €xcDfl rhs€liod ed rh. hsis for lhc al!.scd crmplion. Anv viohrion of Selion 701 I 5 bv tnv
<br />applic r for r pdnil subjElslnc rpplicadtrDacivilpoaltyofnol'notth fivc hundred dolltrs (1500)
<br />-1.
<br />s otr nq oflhc prcpeny, or ny .mPloy6 silh q'as6 s rhcir $le comp.n rion, $ ill & lhc s'dl dd lht stru.1@ is mr
<br />inrdddl or o,Ir.il aor el. (3(.7044. Bcine &d PrcfsioB Cod€ Thc Conlractoi s Lica* Llw dos not applv lo n ownE oi
<br />rhcpopcny who hiilds or improvBlh@d,ond who do6such No* hnns.lioi h.elf or lhmuBh his or hq oNn cmplov6.
<br />provid.d rhar su.h inpmr.lmc tu. ool inlsd.d or ofiadl aor ek Il hosM thr hidinB or impmvqErn ir $ld wnhin on€ )@
<br />oacompl.tion, the ol,n6 Ruildq will hav. lhc bu&n orprotug th, hc or srrc did nor bnild or impmvc fi. F.Pdv aot rh€ ,uIFs or
<br />l. sow -.fth.prcpdly, m€xclusiv.ly.ontaclin8 liln lic *d conkadou to co.stild lhc poj..l {S<. 7044. B'6ms
<br />and Pma6ion Codc 'l'h. conlt.cloi s Lic€ru€ L$v dod not aPply ro m ovoq of ptopd, wno buil& or inprov6 lh6@n.
<br />and rio @nlE.ls aor such prcjc.r wnh a Co.raclo(s) licdsd l6Ml lo thc Cont.clols LicGe ljsr'
<br />I m e\.'nfl unnd S(tio
<br />WOR(ERS' COMPENSATION
<br />DECIA8AUA!
<br />I i@b, al6m unds Fflalty of pdiury orc ofthc followins d.cl@rioBl
<br />I harc od vill ,Binlai. a C.nificalc ofconsl ro S.lf_lNur€ lor vort.rs conrpdsalion s provid.d f.r bv Sdlio^ l?m or ih'
<br />bbor Cod4 for lh. pflo,:@c. otlfic woi( lor vnch lh. pdnit ie i$u.d.
<br />-l
<br />ha!. sd will ,naintain wor*.r' conFsalion i6u&cq 6 requit.d by SalDn l?Oo of lhc l,ab.r Code aor lh€ Ffor@" of
<br />rh. qor| lor shich lhis p.mn s niucd. Mywort.6 codFtuar
<br />!csci'1v o i.(i a
<br />I ccnilylhal in lhc pcrfoirnanc€ ollh€ wotk ior whi.h rhis psmn is issu.d. I shallnol onplo! rv pemn in anv fla'ns
<br />& d ro bdom. srbjd lo lhc \0&6 .onlp.Nl ion l.\es of Califomi.. .nd asl* thd if I 3hoold b€come suh4dr to I hc
<br />\ork6 compsalion Forisios oiSerion l?OO orrhc lr.r cod..I slEll. ronhwirh co,nply $ilh rhoe,mvisions
<br />\IARNING: Failurc ro s(uc Ndrk6' compGalion ..vmge is unl.waul. ed shall n'bjet 0n e.plols ro aininal p€Ehi6 tud
<br />civil li.s up ro onc hudrcd lhorsd dollm ($100,000), in ion, d.ma,r6 s provid.d lor the
<br />s.crion 10?6 ofrhc Labor Conq inld6t md.lbrey s le6
<br />DICIAAAIIA!
<br />I hftbv amrm undq DgElry of p.rjury lhal I d licos.d undd pmrision olchapld 9 (comndcin! with S.clion 7000) 'r Divisi'n I
<br />'4
<br />,.,.,' l\/(,
<br />L.rln r AC.n*q
<br />-
<br />AfII,ICANLDSCI.AEAUO!
<br />I lEcl, ifim undcr pcnally olpdjury onc olthe lolloNlns daldarions:
<br />Demolirio. Pmns-Asb6ros Notificalion F.ddal Regulalions (lill. 40, Pan6)
<br />-Rcqut
<br />d L.ttd of Nolificaion
<br />-I
<br />coriay tbar rtc fcddol csllalioE Egsdin! Gb6tos ,@o!.1 e. nol appkabl. io thG pojc.l.
<br />-l
<br />cdiry thd I hav. @d thii .pplicalio. dd siat. thal lh. abovc infot t lion is coFel I tgr6 ro omd y rirh all cityand (outrly
<br />odinaN6 sd Sr,e bNst Llins to buildins h6€by authortc rcprMlarivs o anris City and countyto dl6 upoi (h.
<br />xrr\. n.m '.nrd DR,Dd\ lur insD4rion
<br />^***, - *," a**,*" b *",. \luJ1 g
<br />ID/SIG.COMMENTSSITE-WORK DATE
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />a\
<br />Yl4,Jt)Loubt JotNL,l - n"'4'
<br />FINAL \-z>11 v,wu)l
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc.
<br />+
<br />**V\.r!! !
<br />Flood Zone Certif.
<br />V,^
<br />U
<br />-T
<br />I
<br />=
<br />o"r", - \r/tp /lb
<br />of rh. ausins md P,ofessio.s Codc, dd my licss is in iull tor.c dd .r€cl
<br />collratlcrlaNi"EluNalcExcr
<br />I hmby allmundd pd.ahyofp€rjurylhal rhE is a cotrnruclion lc.dinS tSdcv for ih. pdlommc oflh€ worl
<br />'or
<br />trhich lhis penn is
<br />issu.n(S( 1097. Civ C)
<br />\A-4-q-
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