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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE COMMENTS OWNER BUILDER DELCARA ION <br />I h.reby rll-'m ondd p.mlly.a prjury rhar I dn crcinpr 6oh rhe cont,cros' Liccns. tiw f.r lhc rolb$in8 rcMr (s( 70]1.5 <br />Eosinas ad Prolsion Con.)r ny Cit! ot Counry rvhich rcqun6 a t-ssn to construcl. all6. im!rov.. dcmolirh or rQait ev <br />slrucIur€. pnor h ils sum.e, also rcqun6 rhe alplicd aor su.h p.flnn 10 filc a sis..d srdmd ihal l'€ or shc is lic6.d pu6@l <br />ro rhc provisbB oflhe Conlr.ctoas Lic.n*d tjw (ChaFe! 9. Conmocing *ilh Sdlion 7000 oaDivision I oflhc Busi.es md <br />PolNions Code)o! rhal hc o, she i.r.mF rlEefto,n drhcbsisnnrh.all+€dcroplioo. .yviolarionofs..1ion701I5bYanv <br />applicanl for a pmn subjdtsrh. applica lo acivilp€uhyofnor morclhu,iYe h!.dr.{ dolltrs ($500) <br />I. s o$n6 ollnc popoly, or my.nrployc $ilfi vas6 s lhcn sG conrPensal ion. vill & the wolt d lhc s,lrudd. h n'r <br />inlqd.d or o ffd.d lor el. (Sa.7044. BBins dd PioasioB codc I hc c ont.clors Li.cnsc h$ do6 nol arplv lo an oMcr ol <br />rh. l'opdy Nho builG or improv6 $q@n. dd who do6 such *o* hms.lfor hmclfot throush hi! or hd osn.mplolc6, <br />plovidd thlt such inptuvddis ecnor inlen& oroll6.d rorek It ltu$6's. rhcbildins or inlmrman is Fld rvithin on. !s <br />ofcompkion. rhc Om6 Buildd qill M\t rhc hrdo ol prolins lha h. or sh. did d toild or i'nFor€ rh. poFlv for lhc purlDe or <br />I. s.s'n6orrherropdy, dn.xclusivcly cortacrinr wnh li.med co.traclo6ro coErflct th€ proj6l (S( 7C\41. [tumd <br />and AllNirn Code lheconlra.roas Liccns.l-nN do6 nor applylo on olv..r oiprori€rly sho blildsor inpto'erhdsn. <br />and yho contads ior soch prcjds Nilh a Coihdo(s) li.m.d Pu6unt lolnc Contracrois LicoF lrw) <br />_l o cre'nfl und6 Sat <br />woR(E&s' conlPENs^l loN <br />DEC!A!t!t!!! <br />I hschy.llirm undd p.Mlry ol psjury one olfi.follo\vins deldarions <br />-l <br />h,r. Md Nill mainlain a Cdlilic colcoMr ro sclt-lnsur€ lor wo.[ e6' con'p.nsa ri6n. 6 p"6ridcd for bvSelioo]700 ollhc <br />I abor Cod., lor rh. ldtomancc oflhc s'ort aor $hich rh. P6nit is isu.d <br />d*andwillnainrainwo.6.o,rp.Balnrni6ura.cc.4scqrn.dbyS(tion1700oarh.L.b.rCod€.Iorlh.pdaonnmc.or <br />ao, shrchthspn'i n ir.ued MJ s'le'!'comr6vr'^n 'tu.'mn.elmo d[.oli.\ numberdcNql i"nvy't le <br />-7 l-t1WL jjLS z <br />Iccniryrhd i. lhe pdloman.c ol rnc wort ior whi.h lhis p.mn is issu.d.l sh.llnol onplo, vp.eninrnvmmnd <br />$ 6 ro beon. subjd ro lhc tr!,k6 co,npoEliion la\$ of C.lifomi.. dd lEc $ar if I should b.come subi..l lo lhc <br />{0A6.o,rpNtionprovisi.Bofsslion1700oalhelnborCod..Islull,forlh$ilno'nplywithrltosPmvisions. <br />WAIiNINC !-ailur€ lo $u. workcB' comp.tusalio. co!.Er. is ulawful. ed shall $'biel d GnploF lo aimin.l psElli6 md <br />lo onc hundr.d thousnd dollas {$100.000), in addilion lo ln€.up.Nation. d.nas6 s f,ovidcd fot lhe <br />s(tion 1076 oithe l-abor Codc. jnrss:l md tomcy <br />I / - (a'/4, <br />Ltcllsurlll[t&(raBDr(! B lloil <br />I hs€by amnn undd'pcMlry oipgjury tha! I m licc6dl undq povhion ofChaprd 9 (conmfl.ios snh Sdio. 7000) of Diition l <br />ol th. Ausin6 dd PmrissioBCode, ond my liccB is in aullaotc. d.rd <br />13 ?r5or o-(7-(Conr.rclo.: <br />I hcreby alfm undd Fenali, ot pdjrry lhal lh6c it a codrd.lion kndins ardcy lor lh. Faonn c€ ollh€ *orl aor shich this pomn n <br />issucd (Str. 1097. Civ. C.). <br />l..nder'! AdLl,6 <br />- <br />A.SII.ICANLIECIdBAIII}Ii <br />I ho$y armr u.d$ pdall, olpcrjury onc oflhc folk wins ddlaralions: <br />Dcmolilionfcrmils-Asb6losNorincarionl€dcralRcsul.tions(Iirlc40.Pan6) <br />-Requtcd <br />Llrtd otNdifi cdion <br />I cdiir rhar lh€ f.dsal r.s!1alio6 r+rdins 6h6tos rqnoval de not alPlicablc to lhis ptuj{r <br />-l <br />cglilylhar I havcrc.d this.ppli.alion dslalclh?llheaboveinfonnarioniscotr.d.IarreroconrPlvNilhallCn,tndCounlv <br />ordinaacB ed Surc L.*s rclrins ro hildin8 con$rucri.n. ad hdc$y atrhotiz rcpr6dlair* olihh Cilv and Cou.lv lo mls uFon lhc <br />ahvc hcrion.d propaly lor iBp€.lion <br />1pt,li.s l or.\Arnl SiIn <br />4;.1.,.a I r(onl6lcorT e <br />t t-t, - (2 <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Brown Coat <br />[,4asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />n- <br />FINAL ///"*/d U,W' <br />Certificate of Occupancy ' '/ <br />Notes, Remarks, Etc. <br />ID/SIG. <br />Subf loorA/enVlnsulation <br />Ext./lnt. Lath I