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BUILDING- INSPECTOR RECORD
<br />SITE-WORK ID/SIG.COMMENTS OWNER BUILDER DELC RATION
<br />, hcrcby afliirn undd ldalty of p€rj'rry ihal t cx.,npt liom lh. Conracro6 Licd{. Llv loi rh. following Bon (Ss.?01 I 5
<br />B6in6s dd ProfBioo Codc): A.y Cny o. Counry which rcquirB a Fnir ro .Dmrtud. alrr, i,npove d.nolisfi or E?ar ,
<br />$rucrEe. rior ro i'i issldce, ale equn6 rh. applicet for sr.h F nil to file a siSn€d slalmml that hc o, sl& is licmsd pu6u t
<br />ro lh. provisiod of th. Conrlaclois Lic.nsd Law (Chaprr I, Codm.n ing *ilh Sdion ?O0O of Division I oalh. Ausins ei
<br />Ptulcsions Codc) orOd h.or sh€ ir eronpr rhacfro,n ed rh. b&is lor th. alLgcd €rdrFion. Any liolation ols.cli.n 7031.5 by any
<br />appli..ntfora!€milsubjErslhc.ptlicantloacivilpcn.ltyofnolmorethanfiv.hundrcddollus(5500).
<br />l. s orl@ of rh. l'oFny. or hy @ployas wnn wag6 d ln.n slc onlPa!.lion, wiu do thc work d$Gnruclu.E rcl
<br />inteid.d or ordcd for sale (Sa.7044, BcinN ud ttot6io6 Codq 'rb. Conrdclois Liccg tts do6 .ol appl, ro d otrn6 of
<br />rh. pmp.ny who hrilds or ihprovB th6n. dd qho rlod sch Md( hims.lf or hdFlfor Ihrcwh his or h6 oM mployc6.
<br />Drovidcd rhar such inFoldMrs ac mt inrqr&d or oFsqj for slc Il hosd6. rh. boiuhs or ,rpr.lmor ie $ld wini, on ,@
<br />ofcompLrioh. 1hc Oma Builda will h.ve th. hrla of Fbving fi,1 b€ or she did mt boild or imptuve lhc popqly tot lhe pupo* ot
<br />l. s ownd ofrh. Fopaly. !n qclusivcly €onrdif,s silh licsEd conrm.loB to consruct rhc FoJ..l {S.. 7044. B$m6
<br />and PoGsnro Cod.: Thc Cooracroas Lic.ns.lrv do6 nor aprlyro d o*.d ofpropdly who builds or improvslh.rNn,
<br />&d $ho tuntB.l3 for $.h Fot..ls wirh a Cobthdorls) lic6s.d puEMl !o th.Conlraclor s Licffi Lsw)
<br />I @.rdB u.dr S-tion , B. & P.C. aorthL 160r
<br />Drte Owtrcrl yo.Bxfal,cau8Ersarlq!
<br />DITCIAAAT!9!
<br />I ha.hy.iIm undd po.lr] ofpduryon. ofrh. aollowin8 delsrarioN
<br />I ha!.andwill mainrain. Ccniarcalcoaconsllo S.lf-lnsur. for qo os onps6aioE 6 rrcvidal aor byS*tion l?00 orlhc
<br />txhor codc, aor th. pEfoanec€ oathc wort for which th. pdnit is Lssu.d.
<br />_l havcandwillEainrarnworl.6 coop!.sarion iBurdcc. a r.qunql brssrio.lT00ollh.L,borCode, for Ihe p6fomMc€ ol
<br />rhi. p.nnn i! i$u.d My Rorl6 omp.nsrion insurecc cdid ord policy numb6 {c:
<br />Zv'r9^
<br />Irluz->orn,r,.* -.{4--1! 7-fub -Erpi6 4
<br />I cdify rnd in th. pefoman.. oarh. wort for which rfiis p.rmil B issu.d. I shsllno! flployany p.e. i. ey m&nr
<br />e s lo b4t € subj*t to th€ sorr6' coipftatio. la* of c,lifomia ed .g@ that if I shorld t com. subjdl lo Ihe
<br />Norl6' comp€.stion provisions of Sdiod 3700 olfic Irhor ( bd.. I shall. fonhwi'h comply wnh thos PlovisioB.
<br />wAR\tNC: Failur.lo su. workdr snp4arion cov.@!. is unbw6l. sd shall subj..l m oplo)Er lo oininal Fulti6 ond
<br />oivil fincs !p ro o.. hundrcd lholsd dollds (5100,000), in addnion lo the cost of comp.Mlion, danasd 6 provid.d lor thc
<br />rhe tnhoi cod., int6d,nd dtonq s lB.tl ,\qlat +fwt'-'a f-
<br />t,tcLNsul, coNr{ (toR
<br />DIiC!,llA Ilot
<br />I hcrcby a']jm uods pdnlty of ri.rju,y that I m IiccG.d undo prcvbion olftaflc 9 (.omm.ing wi$ S6tio. 7CS0) $f Divison l
<br />of lhc Busin6s md P,oasioN Codc. dd ny li.trc is in lull lore ed elTat
<br />,."*"a* e' /'LoLo SOb
<br />n"" ' ?q
<br />CAISIBUCII()!-tE!D$Cr!CIr!CI
<br />Ihcrcbya,lim.dapaalqofp.rjurythatrh@isacon$tucrionlodingaSncyfor$.paaonnMc.ofIh.vorklorwnich$jsFmiis
<br />issu.d (Sc 1097. Civ. C.)
<br />ATTII(:ANLDICIABAIIA!
<br />I fiftWamm unds pcnallyolpqiury one ofrhe lollowi.! del&arions:
<br />D.molition Psmits-Ast6ros Norification redcral Rc8uhlions (Iillc 10, Pan6)
<br />Rcquired lnt6 of Notifi cation
<br />I .dify rhd th. aaldal .esularions €sanlins GLsros lEnoval {e nol spplicabl€ lo thn pnJ..l
<br />#g',*lI havc rsd lhis applicaiion and nalc fomarion is c.@r I a8ra ro complywni.llCilyand County
<br />iic Ln(srclali0r lo buildiqr n'a ofthis Citydd Counlylo cnt6 utIn lhe
<br />abovc rctruon.d propdy lor
<br />Applicrnt or ACdt Signit"re:
<br />"".,ti,* ,"." 1pt:nq, -f
<br />l-zlL,Iz*a
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenUl nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<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 />FINAL llq ?-D )ftrrnor #89
<br />Certificate of Occupancy \l
<br />Notes, Remarks, Etc.
<br />DATE
<br />Ext./lnt. Lath
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