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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNERBUILDER DEL(-ARA ION
<br />I hscby afiirn utrdr pmlty of r€.jury lhat I an clear lLom rh. conttcr.a' Liceise Ld* lffrhe a.llowin! 1t6on (sec.70115
<br />Businss dd Proa6sion cod.): An, ciry or Counry (hi.h r.qunB a pdnrn lo consnld. alt6. impro\€. doolsh or rerEtr any
<br />sle!1u.. rior k, its isuance. also r.qut6 the applicanr lor such peflnrr kr file a sisned srat€mqr that hcor shc 6li.dsd t6udr
<br />lo Ih. Fo\isions ol th. Contncloas Liccns.d tjrv (ch,pr.r L (.(nnnrn iig wnh selion 70L\) of Dn'bion I oa lhc llusiness ed
<br />Prolessions Codc)orrhat he orsh€ is €x.mpl thEciom md llE tr6is for lhc alles.d €xoprion. Anr- viobton oas.atnJd 70r I 5lry atry
<br />appli.mr ror atcmir snbjNrs rhc dpplicantoadv,lpenalryoanornor.rhMnv.hu.drcddollrs(5500).
<br />L a osne ollhc FoFrlt, or my dnplotB snh {as* d rhct sn. .onrpdrslion, \rill do the $ork od lhe $nrc1ue s Nl
<br />inrc .d orolldcd tor ele (Se 7([4, Lrusin* d Prcf6sioN (odc lhc Ci,nhdor.l-te.* I-a$ do6 nol alply ro o otrn€' or
<br />rh. phtdy Rho b{'ilds or iinlyors rh.on. dd who do6 nich N!* hinN€lfor hmclfor though his or h.t o\w enployeB.
<br />provid.n rhar such iryrcr@.nrs @ nor inlod.d or onsarj ror elc I I ho\vd d. $e &ildins or nnproEndl is $ld * ith'n onc y@
<br />oacomphn . nE oNnq atrillg will have lhc burdtr olprcrins rlEt h€ or sh. dd mt bu[j or nDprole lhe propqry lor rh. puls* dl
<br />l.asosnerollhepropfi). n erclusivcly conlracrins \irh I'cen*d .ont{doN ro ..6hd rh.,,ojd (S.r 7044,lr6rn€r5
<br />dJ Poieasion (bde: Thc (orrractois Lic.nsc Law do6 nor aptlyro.n o$trd ofplopen) sho builds or nnpnn6 lhersn,
<br />and \vho conimds fo. such prqds with a Contrrcro(, lice.rd pusudr nr the cdnti.rorr I-icds. hw)
<br />-l
<br />m cxcmpt undq Srxon-, B & P C. for $is r@n
<br />D.re Ofrner:
<br />li!.8!iE8S1C9!!!!LSr!-LlO!pEltAB3lrra!
<br />I h.(by affin un,t6 pdahy of rriury on. ofr h. fdl$vi'u dccltuarn,ns
<br />Ih.vead\villmintain0Ccniicarco,CorsntloSelfJ$trrcforvorksiconfens,rnrn.atmvid.dlorbys.diotrl?00otthc
<br />lnlsr aodc, aor Ihc pfiloandce o f lhc work for \ hich nrc pmnit is isuen
<br />I havc and sill mainlain wolkets comgcnsal ion insu,ance. 6 r.1luir.{ by S€i on .1700 or rhc Lth4r cdd., for tlE p(fom ccoi
<br />'1
<br />s \str!\i NlYro l.h (u Lon insu.atue ctmid and Bnic) nunrbd tuc:
<br />/o7u A, *-
<br />_l cenifyrhat 'n rh€ p€rformlnce oathe \rorl for shi.h rht p.nnir is issucJ, I shallnut dnploy an! pdso. i. any flrmncr
<br />$ d ro b.en. strbjdl b the sorldl .onpmdion la{ s o I Cililomia a.d agrc rhar il I slNuld becomc sbjLrl re lhc
<br />$ort6s conrpdrarionpiorisionsolsNrio.lT00.lrlrLahrcodc,Ishallhnhwnhcomplysirhlho$prorisu,s
<br />WARNING: liflilwe lo wurc qolkod colnpsation covsasc is lnhs rul. and shail subjdr an mtlo]s lo oiminal rsmltis and
<br />cnil fines up to onc hundred rholsd dollau ($100.000)- i'r add(i.n r. thc.o$ of.onlxnsariotr. d nascs c provided lorlhe
<br />(i\1. n.,.1ritrd.rlf'trr\ s lc(1
<br />tl Appli.rnl:_---_._
<br />DECI,6AAIIA!
<br />I n.rcb, ami,n u.d{ pddltyofptrjury rhar Ln lic.f,s.d undd prevision ofCharlg 9 (conomcins $nh salion 7000) oaDivision l
<br />of lhe B6ins dd ProlsioB code, my li.ds. i in atrllao,eadcllel
<br />,',"""",,,*"4Q( /<74 ?/r4'!lft/d'14y',*//4k
<br />catilBl,icuoxL[N.allc-&GEli(r
<br />I hEcby rfiinn und.. LEnally oi pqrury lhal th6€ s a conslru.1io. E.di,! ascncy aor rh. po aomdc. olrlrc \ork aor shich this Fmn is
<br />hsucd(sc 1097.ci! c ).
<br />L..der s Ntrme
<br />afB.rcaMDEct aSalll]x
<br />I holty amm und6 p€nally ofp€.jury on.olthe tollowins d€claalions
<br />Denrlition Pftnn$Asbeeos Norificai ion t'.dsal Rqulations (l nk 40. P.n6)
<br />-Required
<br />txlld oi Nolifi carbo
<br />I .dilr rld rh€ fcd.r.l
<br />'luularioru
<br />resedin8 slB6s rcmo\il ac nor aDplicabl. to rhis pmjcct.
<br />f-hd,[ rldr I ha, e rqJ rhr app](,r'on od sra, e lhar rh€ abor e
<br />'n
<br />tunnarn,n
<br />'s
<br />cor(l I asre ro co Dl, wnh all (-ry and (-ounry
<br />&dm\R6 J Srak Lnqs rehrrns ro bu,ld'ns conrrucl'on, dd h6ebyaurhorize Epr6nlariv6 oarhis Cny dd countylo atc olnnlh.
<br />ab.\ . nBtrioncn prop{tt ior nq€.rion
<br />Appli.,nr or ,{Betrl Signrtu.r
<br />l'ci,trilrr n{n,rlp.itrr):
<br />,rrr" lh/f
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenUlnsulation
<br />Roof Sheathino
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />[,4asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />En gineer Final Report
<br />Flood Zone Certif
<br />I
<br />FINAL lllzrl14 .1'12$d,\
<br />Certificate of Occu anc
<br />Not es, Remarks, Etc.
<br />Ereclion Pads
<br />I
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