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BUILDING- INSPECTOR RECORD
<br />ID/SIG. ,COMMENTSSITE.WORK DATE
<br />Set Backs
<br />futtA /n_Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Aar *r -Subf loor/VenUlnsulation
<br />,lRoof Sheathing
<br />;;31.-"atr,Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drwvall ,,79,tl1,-----'=rtZa96x61.NtlExt./lnt. Lath
<br />?fn /olBrown Coat tl
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />F|NAL 1 /.1//7 r-hlb
<br />C e rtiti c'ateb/ O cc u pa ncy
<br />Notes, Remarks, Etc bu o
<br />-----T------
<br />L/4 -
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<br />nb BetYn/
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<br />(-q
<br />/2_
<br />,/;t/u x_
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<br />I hqeby afi'ri,n undn p€nshy ol pdjory lhor I m dc'rpl non th. Cohrtacrots' Lic..sc Law for rh. lollorvins rcen (Sd 701 I 5
<br />Busin6s and Proldioo Cod.): Any Ciry or Counry *hi.h r.qut6 a Fmn lo coNlru( ahs imProv., d@olish or rq€t 6v
<br />srucrure Fior lo il! isu.n c. also rcqutB lh. spplicml for such t mn ro 6l€ a sis.nl stardral lhal h. or she is lictucd PUBU&I
<br />ro lh. ptuvisios ofth. Cont.clois Licenscd I-aN (Chapr$ 9. Comrdcnrg wilh S..li.n 7000 of Division I oflh' ausind dd
<br />Pslcsio.s Cod€) or lhal hc or shc is cxmp rhd.li.m md rh€ basis lor rh. allcs.d crmprion. Anv riolarion of S'dion 701 1 t bv ov
<br />.pplicanlforapmlsubledsrh.arplicmlroacivllpcoalryoanormor€rh&fivehundcddotles($500)
<br />rBE.sourorrLcpopcrr.orri).mpro)dsirh{466th{$lcconrpoerion,silldolh.*orkedfi'srurdcnmr
<br />---a-r *"a-^rr.i cl].rio 7ei4. 86;6sd Pmfsioc cod€, Thcconracroas Lic . L.\v &6 noi spplv ro u o$nd ol
<br />rhcpmpdy sho hild6 o. nnprcyB Eon. dd who &6 such tro.t hihs.lfo! h6clf or rhrooltfiis or hr own 4plov'd'
<br />p,o'U" rt',r.u.t inpmmrs eml inl6&lororq€d lor sL lt hosos.lh€ hilding or inprorc@l iseld silhinoft )a
<br />;fcompLrioq rh. OM6 Builds will have lh. turdar ollrcYns td h. or shd dli not build or imltov. fi. Prcpdv tor lh' pnrFs of
<br />-1.
<br />sosner.flh€ p.opdly. tuncxcluivcly co.lra.rinB snh licds.d .onradoG lo co6itud lh€ ptojdr (Sd 704'l BBinN
<br />-a n,ro"m Coac, rttiCo"r,adot s Licms€ Larv do6 nol tplly ro u orvn( ofprop.nv*ho builds or inpror6 rhBon
<br />d who conrmds for su.h pmjds wirh . Contodo(r lics.d pu6udr ro fic contaclm s Licosc La*).
<br />lrn.\.md undo Sat'on- . a & PC lo' ths r.Mn
<br />un" . 11. /7(..t C- **, Y t...--^-^*' o \o8trErl-caull!.:alo!
<br />./4b
<br />DECt-{RA'TION
<br />I h6€by amrn undd F&lly of psjury on. ofth. lollo*inB d6lealioB:
<br />-l
<br />have a.d will minrain . Caiificar. of Cotud lo Selalreure for *orkcG $nDe.elion 6 proid.d for bv S*tion 1700 ofln'
<br />tibor Cod., lor th. pdfomdc€ of lh. $ort for whi.h lhc pmil is isu€d
<br />-l hav.and *ill mai u wo*.G' compc.satio. iNuaEc. 6 tquircd bv Srl ion 1700 of thc Labor Coda for tlel,6'ommcc 'r
<br />Oe worl aor which lhi! pasn is isucd M, workdt compdsdion iBurmcc camr ed policv nudbd rc:
<br />Poli.y Numbq:-ExP
<br />l(11- Lcn,rr rh rnrheFrlrnDncenlrhctrorkrnr$hrchnrispsnnlisisstr.d.Ishallnotdnplova.vpo.oninanvno'd- - m rc tct.c rUei ro rtrc tr orLd .ompNuotr laws of Califomia. dd age rhd if I should b'{omc subj€ct ro rh'
<br />Nork6 compdeiionpmvisioNolsdiot l?OOollhc t.ah,r Codc.l sh.U. aodhwiih complv sirltrhos prcvnioN
<br />WARNTNC 'l'ailu.c r"'*,r. ert6'anlp$.rion covsaS. i5 unla$ful. ud shltl subjer a! oplold lo mminal l*nalli's 'ndcivil fin6 up lo one hundrcd lhoMd doll6 ($IOO.O0I)), in addnion Io lhc cos of conrpo$ri'n. 'lmas's e providcd ror rh'
<br />Sdion 1076 ol Ihc l-.bor ('odr. inrs6t Md rllomcy s lcs
<br />l-t( ttNstD ( ()NIRA( l()R
<br />DPCI,ASAIIA!
<br />I hs€by aifiro un.l.r t nahy of pojury lhat I m licdsqi undr Folision ol ch,prs 9 (conmcn.int wilh Scclion 7000) or DivBon l
<br />oa ihc Busin6 &d PofsioN Codc, and m, licsc is in tull foicc .nd eifel
<br />CONSI XTJC'I'ION LENDINC AGENC]Y
<br />I hcreby amnn trnd6 p.naky o I lerjury lhal rhft i! a codtud ion l€.dins agmq for Ihc pdlommcc of the $ork for shich lhis Fnrn b
<br />issued (S(.3097, Ci! c.).
<br />L.nd.''r Adrt< '
<br />APPI ICA N'I' DFCI ,ARA IoN
<br />rnnnundcrp.nah) olFlu'\ .ncolt\eln'o(inrlnluar:ons:
<br />Dc Nlnion l'ermirs sb€bs Nolinclrin Fcd.ral Rcstrlnhons(Inlc 10. I'ano)
<br />Ro$ircd l-cneroaNotifi elion
<br />l\
<br />"!*,-i,iT"!",T-i*Ylffi ...,.^_/q_.
<br />,...u*'".",rnn,,, !K&+r-,aJL,,/.QllEl-. .
<br />//4419
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<br />rt-taDd-'.i- ,; -nha- - -( l- -' -v
<br />u/.c/z , )&ra .?z rZar' ,e*zS* zdrcel'"
<br />/,e-Fz.aE- h(hl,'/la fivzi,zan'l "^ A-tt tz48qz--
<br />D"c,. /1. )6. / ?
<br />LiccN Cls:-Lic@. Numbdl
<br />Drte:-- contr..toi-
<br />L.nd.r'! Nam.
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