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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDEN DELCARATION
<br />I h,r.by.rtr u ndcr pcnahy ol l]{rjlry rhd I aor erc lPt riod rhc cotrtucrom Licc.e ti* ior Ih. rollowinS rc!$n ( 56.' ?0:11.5
<br />tsu\incss lod Porcsion C.d.): Any City or Coutrl, which rcqutcs r Fnnit b $nsld.l, rllcr. i'n!rcvc, dcmlirh .r np,t 0try
<br />{flcrur., trnb irs issuamc. ak. rquncslhe applicanl lo, such rEmir ro lilc. siEtfd st(tcrEni rh3r rEor shc is liccnscd puFu!trl
<br />ro rhc prevhions of tu Cont,.rors Licctrscd l-rB (Cnaprcr 9. Comncnciis snh sc.rio. 7fixj ol Divisio! 3 .r rh. Busincss and
<br />Pnna\sn,ns Cod.) or rhd hc or shc is cxcnrfl rhcrcliom! d rhc ha\i\ nr rhc dllcgcd cxcmprion An, viol rion.lSNlinn 70:ll5 hyuny
<br />rpplicanr fora I'cmir suhjarrrhe aptlicxm ron.ivilFnrlryormr mrdhin five hrnnrd dolles (s500)
<br />L r\ owftr uf rhc pmpcny. or nry cmphr€es Nirh *a3cs as rhcn {r. .on1F sll i(r $ill do IIE work md df, slrururc is nor
<br />inrcndcn or ofi!rcd for Elc (Sa 7044, Bu\incs Md Ptofc$ions C.dc 'fhc Contr.ktr\ Liccn{ tj} docs nor lpply r. M owmr ol
<br />thc m)o.dy who builds or immres rh.mn.,nd sho dod sxch *oA hnnscllor hcrclf or rhnrugh his orhd owtr cnPi,yees.
<br />prolnbd rhar su.h improvdmm 4 mr intclrd.i o, ofieEd br elc lf, hoktr. rh. buildi4 or ifllorovcnEnr i! sld *irhh .nc ]tr
<br />ofcorylcrhn. rtE O*mr Bniklo will ha\r rtr bldcn of pr.viry lhat lE or shd dil mr t ild ot irY{mvc rhc loFny nn tul)urFsol
<br />-1.
<br />trs owrcr oa l he proFnr. ah cr.lusntly cotrkdctnrs w irh liccn\L! coittrcds b .onnrucr iif, I,r+cl (s.. ]o14. BlqRs
<br />nnd P$f$bn Codc: Thc Cont0cror's l,ic.n\c l-iw do.\ nor applyt,0, osncr ofproPcny rho brilds or i.npn,vcs rtcrcon.
<br />lnd *ho ornkac( fd su.h nmjcds wnh r ConrBcto(s) lice.scd pu*xrnr b rhc Gn a.kx s Liccn* tiw )
<br />I r'hcrcmDr undcr Scclion .B &PC lcrhFrca'on
<br />()Bn.rl
<br />.llll8trE8f.laM8ElsArloN
<br />PECLAMITQ!
<br />I h.fby aflirm undfi r.n,lty of lcrjurt om of rhe touowine ddlararionsl
<br />f, n*" * *, u ,.,,
<br />"'^ "
<br />acn,ficorc nr cnnrnr ro sclr lnru.. rd wotk.rl conpcnsol ion. !s providcd ror by scclion l?m or rfic
<br />Uho' C-d.. ,i tr rhc r{rlor nlmc or rha wor l lor r hrh l hc Fl m n ntu.d
<br />-l hlvc ond vill mai.loin worlcts conFnsarion insursNc. as Bluncd hrS6rion lTmof rhc LihorCodc, for rh. FrrorNNc of
<br />1{0,c My workcn- conllINar io. irsurancc crricr drl lblty.unrbcr ee:
<br />rf (ctcZ\r6ot))tl
<br />I ccnifythar in rh. IljrfornEmcolrhc *ork lo! $hich rhi\pci,nir i\ isnrcd,I sh{ll nor cmployanyre*.n in rnynnmnct
<br />so $ h bcconE subicr ro rhc $orkc^' conncflsor io tr hws orcalilornia. lnd rsrec rh{ irl should bNonE sutjccr r. rh.
<br />Norkc( compenslrion novisions ofSc.rion 3?(nolthc tjho, Codc- I lhall rodhwilh comply with lkE pmlnnnN.
<br />WARNINC railurc ro scurc sork * .omp.n{ion ovca8c i\ unlautl. and \hrll sxbF.r 0h cmplorr t) aiminal Itntrlrar r d
<br />civil fincs u, kr one hunddd rhonsaM dollaK (t100-Ux))irion t, rhc coer .f conDrnsarion. dsmAcs r. povid.d lu rhc
<br />Sccrii{:1076 o, rhc L'ltr a'.{c, i cr.{ ron aiktrry r
<br />F+t-<.1, ,t
<br />DECIJaA.IION
<br />I hcrcby afllnn undcr rcnallyofpcrprr rhar I !d liccnsi und.r pmvision olChalrcr 9 (coD.rn.inB uirhScclion 70(n) nrDivi{inn r
<br />of Ihc Bucinc* ed Pofcssiors Codc. aod my liccnsc h i. tull tn€ .nd cfi:,
<br />o zl?s )) (
<br />1 F-tl <-
<br />CONIiI&IqIIANIEIDING.EAENCI
<br />IhcEbyrmnnundcrpcnrlry.lFrlnryrhilth.rcnncosru.liotrlcndhsolcrt,irrhcp.rfoal$ccoilhcwolkrirwhi.hihisPcmitis
<br />n\ud (Scc 1097. Civ C )
<br />AITLICANLIEII.A&IIIgN
<br />I bNny afirn undc! l]codry of t rjuty onc of rhc lollor ir8 dchd i{ins:
<br />D.nslirion Pcrmih-Asbcsros Norificartun F.d&rlR.!ulnlions(_tirlc 4.0. Pln6)
<br />R.quicd hlcr of Notirtllion
<br />-l
<br />ccnifr rhar rh. rcd.rd rgullriotrs rcsudins ashcsros rcR,vlllrc nn aldi..hlc ro thn ptojccl
<br />l.drilylhnl llwc rcnd rhn applicari,,ddd {arcrh r rh. ntbvc itrfrnulnr h cotrccr l agr.. ro.. ywilhollCnrrtrdCoxtrry
<br />ordnrD.csa Strlcl-rrsEhrinrI rucrnJn. nM hcrch, rurh.r r.prc\cnr,rivcs orthh City!!d ct,unryro cnrcr ufl,n rlE
<br />abovc nr i.trcd Imp.dy lor i
<br />c4 lLr'l Lltty
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq i olLglR@ urt<*(71.t)
<br />lnsu lation/Enerqy r t t(
<br />Drywall [['2?-/9 ,t./rt*r'qD)
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />T-Bar t2-t1-ly Y.\all1t)
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />FINAL 41 24lra'I l/araa.fL^r )za)
<br />Certiticate ol Occu n
<br />Noles, Remarks, Etc
<br />Flood Zone Certif .
<br />Z
<br />l.id.a. Addr.s
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<br />I 64
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