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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BU!LDER Di]t-CAR TION
<br />I hc6by anirn r dcr rcnah, r)r p.aury rhd I m exc'nlr from rtf, co radors l,ic.ns. tjw ro.lhc lnlLsinE rda$n (Scc 70ll5
<br />Busnrss nRl Pmlcssion Codc): Any Cny or Coumy which icqutcs 6 P.trrir ro .on{rucl. ollcr inPtr,rd. dcnDlth or EPrt v
<br />(rucrlE- prirt, ir\ issuarcc. aho rcquirc\ rhcamli.,nr ror suchFrmir t, rilc, \i8ncd slolcmnl rhar hc or she n lien\cd luBnanl
<br />ro rhc pmvishns ofrhc Conta.rors Liccnscd Liw (Chapr.t 9. Conmcncirs *irh s..rion 70Oo oi Divni('n I ofth' Busincs and
<br />Pmfcsions Codc) or rhdr trorstu hcxcmpl rh.Efnr ,trd rhchask for rhc trllcs.d cxcmlln,n Anv vbLrnnr of S(tion 7()]1 5 bv rtrv
<br />oppliclnr lo. aFrmir trbj{rs rh( rpplica n, acivillc.rltyolml mtcihd
<br />'lvc
<br />hundrcd dollars {S5fi))
<br />L ds owncr ol th. Ilroli€ny. .r nrt cmrlo)tcs wirh *ngcs a\ rh.ir olc .ompcnqri,,n. will do rhc work Md $c nturu! is nor
<br />inic' cd oroflamd tor elc lsc.7ol4, arsim\snnd Pturcssi(ins O)dc: 'l hc Qnnra.t, s t.ncnsc li*doc\nor.!plvro!iosi.ror
<br />rhc pmrcay sha hilds or iq,ruvcs rlLftu. Rlwho d.c\ \Nh *,rk hnnscll or hcrscllor thrcreh his or hcr osn cn'rl'ivccs.
<br />Ircridcd rhar su.h imfntrrnrnr\ s mr idcndcd orollctul iar elc llln$cwrhcI ildine or inwovcnf,nr is {rld wirhir'nrc $rr
<br />ol.!nu'hti{rn- ihc Owndr auitld will lNc lhc hordcn ofpmlinr lhr tu oi shc did D.r huild or imPnNt rhc |nrFny tor rhc ru4r$.f
<br />-1.a\o*mrofrhrpmtny.rmcxclusnrlycunhdnr!wrhliccnscdcotrtd.r,sro.oDsrru.rrh€pn,l.crlscc.
<br />7oir4.Bu$cs
<br />d ft.i$sirtr Codc lhcConkrcrol\LiccnscLrwdesfloirpllyk,rnowNrofnr.P{nrshobuildsotitnPrclc\rhcrcotr.
<br />ind who conrBcrs rd su.h ,,mtcls $ilh !Conkacn(\) li.clrsL'd Dutsuonr rorhcc.ftncrois Liccn\.I-as)
<br />-l
<br />mr cxcmpr undcr SL\r
<br />Dsle owner
<br />lYORXTRS' C( INt PENSATION
<br />DECIA.S{IION
<br />I hcrcbyafltnu f !.nrlryol!.rjuryoncolrhcnnk,wingd..lurrion\:
<br />Ihivcmdwillnuinuinaccdifi.nrcolConscnlr.Sclfln\orcr(rworkcGconPcnsdtr.asPovidcdtuhvsc.rion17(xroilh.
<br />L:h, Cod.. for thc rcdormancc.f(hc sork lorwhichthc nctnril i\ isu.d
<br />lhavc and will
<br />'naanranr
<br />wolkcrl comncnsrrnrn insuhi... rs rcquicd hy Sccrio. r70l) oirh. Uhor Cod.. ror rhc P.rr''rnuncc ol
<br />rhc wort fttr whichrhiepcnnil is isiucd. My*orkc^ fl,mPtnsrlion iflsuruE-ccuicr *l1 Flicy nunrhct m:
<br />Policy Numblr
<br />-trlncs
<br />I ccdiry rh,r i.lhc pcrfonuncc otrhc work rot qhich rhis Pcrnn is i\ru.d, I sholl nol couloy,ny N^.n in rnv mrni$
<br />$.sk,bcconEsubrc.lr.rh.worknCconrPcrslrionh$\ofcaliftrnii.0Ma8rccrhliiflshotrldtEcoNsubjccibrh.
<br />wor*.c conDcnxarion pft,liriotrsolScclion:lT0OoIrhc Liht C('dc,l shrll.lonhwirh..nrly wirh thos Polisnrn{
<br />WARIINC Fdilurc lo scu.. w.rkcs conltcn{rion coveragc h utrlrwtul- rod shJll ruhFcr atr c do)!r r. diminrl rnrlrics.nd
<br />civil lrncs up lo orc huddd rh.usdtrd dolloF (!l0O.lXr). in rddirioi ro thc cod of.onrrctrsllion. d!mrgcs a\ Pr'vidr'l ftx rh'
<br />Sc.rio.3076ol lhc tihn C.dc. inicrcs. .nomy s fcc!/z-,^
<br />I hcrchyrffir undcr !.r.lryofpcrjury rhrr Irm lnttrk{ ufldcr Drovi\i{n, orCh.Prd 9lcommcncinE wirh Sccrion 7([x]) nrnlvi{i'n l
<br />af lhc Bu\inrs md Ptufcsn,nsCodc. lnd mylirci* h ir tull l.rce aidcrLcr
<br />qolsrBllllu()N-L[xllluc-&cENl.I
<br />I h.{by rilrn undcr pcnalry.l Pcrjuiy rhdr rhcrc n r con(rcri,tr Lndi'r8 nscrcy io ihd P.rroiIrn.c olrhc *ork r.r *hi.h tht ncnni t
<br />hslcd iSc. :r097, Civ. C.)
<br />LcnJcr'. A,ldir{
<br />-
<br />A.ITLIIANLI]ECIABAIION
<br />I hnhy amnn under pcnalryotrqjury oM ofrhc iollo*in8 delnrit,n\l
<br />L)tnnlirbn Pcmih-Astrslos Nolinc ior Fcdcril R.guhriotrsl1irlc 40. Pan6)
<br />-Rcqutcd
<br />L.{.r or Norili.o'ion
<br />I cdrrryrhd rhc fcdcrtrl r.guhrioN rFtrdh! r{r{os I.nxivxlrr. nor n!fliciblc h rhn Px,rc.r
<br />-l.rdifyrha!
<br />I luvd rcndrhis 0!plic!rnn, md dar.rh rhd dbvc i irlrmrnn,
<br />or.linanc.s md Srric tjwsrhrin8 t,l ildi'rgconnrucrion. Md hcrcl'yrurkritr
<br />I agre ro co'nply $irh rllCiryrn Counr,
<br />divcs olrhi! Ciry rtrd C.uniyt, cnrs ull). rhc
<br />ahovc mnriomd pn,p.ny ror iNpcclion Z ppli(anl or Axcnl SiANltrrctu 4.vzb;il
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />I42t/E ,H z*)
<br />Certificate of Occupancy //- ' a-/
<br />Notes, Remarks, Etc
<br />Erection Pads
<br />FINAL
<br />fT
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