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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DEL'ARATION
<br />I hdeb, artrm 0ddd p€Mlly oa pejury lhar I n ermq aron rhc (onracro^ L(.nsc ljN forrh. rolb\da rsg$n (Sd70.115
<br />tsBinss ed Prolsioa Code)r Any Cily or Counly Nhich requi6 a pennt to co6tn,cl, alld, i'npiove &molish .r prn ,
<br />srrudurq prior to 'ts isudce. also rcqun6 rhc applico ao. such [tmn ro filc a sign.d sr.tmor thal h. or shc G licdsed pBu l
<br />ro rhe pmvisions offie Conr,acloi,l-ic.nsed L,s (Chapr6 9. Conmcncins sith S{rion 7000 of Dililion ofrh. BusinN ed
<br />Prcfsions Cod€) or tha h. or sh. i! crcdpr rh@6oD dd rhc b6sis fo, rn. all.gdl amplion An, riol.lion oasEtioD 703 I .5 by y
<br />applicanr ior a pmnir subJe8 lhe applice loacivilp€nallyofnotmorclh lilc hun&.d dollds ($500)
<br />_1, a oMn of rh. prop.ny, or mt anplore sirh w.g6 a rh.ir $1. comp.nsalion. will d. llE {orl dd lhe s!l(r@ 6 mr
<br />int6d.d or off.r.d for $1. (S6.?0v4. Buio* ed l\olsioN Cod.: Thc contaclol s Lic.N tjs do6 nor apply to u owns oa
<br />rhe p6p.ny who b{il& or if,1Drov6 tfiq@n. ,}d who do6 slch $orl hinsclf or h.*lf or rhmusi iis oi hd om cmployc6.
<br />providcd rhal such inipftrad6 ft mr idod.d or olTaol fo. $1. I t, howd6. lh. boildin-! o, ihForffil b $E snhin one ,q
<br />ofcompLrion. tnc o\"nd Bu dd will hav. lhc hrda otprovitr8 ttd he or she did oor liild or inipore ftc Foroly lor th. purpos oa
<br />_1, soMcrof rh. protoly. d.x.lusir.ly.onta ns virh li.m.d.ontrlo6lo onsrrud lhe lIoj{t (Sc 7014. BErns
<br />and Profsion Coder TheConrractoas Licmse Law do6 nor applyto d ow.cr o lprcp.dy sho huilds or imprcvB lh6on.
<br />and $ho co racrs foi $ch Fnjfls wirh a Conmdo(s) lica*d ponMr b lh. Conl8clois Lics. Law).
<br />-l
<br />Me\cno undd S6rioo-. B &PC loilhb rcaon
<br />Drrc: o0n..
<br />WOR(DRs" COIIIPENSAT'ION
<br />Dlict daalla!
<br />I hs.by ailnn unds lqilty of psjury onc ol lhe followin8 d*lratioN
<br />_l hav. dd $ill mim.ln a cdincd. ol consmr ro sela- lnsur. lor *ork.B conrpensrion, d arolidcd for by Sel ion I700 oarhc
<br />I2bor code, for rh. pdaoflm.. of lh€ eo, k ior which lhc pdmil is issu.d.
<br />Zat
<br />-l
<br />cslify lhat in lhc p.rfomoc. of thc wo,k for wbich lhi. pdmit i! i$uol.l shtll nor cmPloyanypsen in dy ndnc
<br />e B to b..om. slbjsl lo tn vorka composlion la$s oacalilomia. md asrec lhal if I should bdon subj(t Io lhc
<br />"oi(6'conp.6ario.povisioNoasdlion3T0OoflhcLahorCodelshall.fonhvnhNnplrwirhrhosprovhionscomFMrnrn co\d3c is 1. md shall subj.d anplorq lo sininal Fuhi6 ad
<br />cosl ol cornp.ns ion. daExes as prolidcd liJr rhe
<br />x*,..1 1
<br />'an
<br />DECLAAAIION
<br />I hcrcby amrm undq pddlry ol r.rjury rhar I an li6s.d !n!d prcvision olchapld 9 (comncrcins wilh SsrDn 7000) olDivision l
<br />of rn€ Dsin6s and Prot6sio0s Code. ud my liccnsc is in luu lorcc dd dId
<br />,,*3-/S?f z-rr
<br />t{,o,F HL
<br />lo!$aiJcllolJ,rNDlNclcffcr
<br />I hncb, allrm undd Fnony of pdjury
<br />'hal
<br />lh6. is a connrudion kndins asocy aor lh. tdfomdc. oao. Norl loi which lnis Fnil i.e
<br />tsu.d(Sd :1097. Civ. C ).
<br />AIIUCANLDI0.AaAUQX
<br />I 'Eor+ dlnnn unds r..aliy olperjury o.c oalhc lollowing dalartbns:
<br />D€nohtion Pdn$Asb6ros Norifi.alion Feddal R.gularions (Tnt40. Pan6)
<br />Requned Ldlcr(aNorirr.arion
<br />-l
<br />cdiiry ihal lh€ lcdsal rcsulalioN rcssdins AbBlos rmoval a. nor appli.abl. ro $is p,o.j€cl
<br />con,ply sirh .11 Cir, a.d Co
<br />his Ciry Md ( ounryto c.ls
<br />,"," ll
<br />-l
<br />cd'6 rlat lht'c 's,j '\6 tot'.ar'.n dd sr.I.rh{ rh. aL!'r. inlonniri^n s cond I a!'(!.
<br />J,l]ln c6 &d sra,. rr$ s Fhrin! ii\y'lrlis odtudrtr e,l hd.D, our io, zc , €p 6ordr!6 o I I
<br />1H---HH::."?j?J]L z, ta-L\\\"..i,*n,.",,.i,,,, 2:T*e A. l4e A f-
<br />Z.> r 3
<br />Set Backs
<br />Forms/Steel/Holdowns il"t7-tK EILfl)0 EJ(r'{r qrrrlT. d.il.\dt8i
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenUlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />A,
<br />FINAL la-7-tg yAuJti
<br />Certificate of Occu n
<br />Notes, Remarks, Etc
<br />7
<br />er q.
<br />e5 32.,z<l t io O1
<br />$ARNINC Failr.lo su€ workm'
<br />civil lurcs up to on€ hundred lhousd
<br />,$r'i t\6
<br />I er.lcr ' ^J.16.
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