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BUILDING. INSPECTOR RECORD
<br />SITE.WOBK DATE IDiSIG.COMMENTS
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Sublloor/VenVl nsulation
<br />Shear Wall
<br />Framing
<br />ln s u lation/E nerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />T-Bar
<br />l!qndicap Req.
<br />De puty Final Report
<br />Engineer Final Report
<br />FINAL rD\\\g 4 iu4.s,
<br />Certilicate of Occu pancy
<br />Notes Remarks Etc.
<br />OWNDN BUILDER DEI,CARATION
<br />I h.rchy rinm lnncr pcnrlry 0f p.rjury rhar ! ani cxcnlor fonr rhc Contackxa Lkcisr liw f(r rhc followinS rc!$r (Ss?031.5
<br />Itusircss rlld P.or'cssion C(xlc) Aiy Cily or Counly whih Elun.s r pcann to connrud, alrcr- impr.vc. dc $]i\h or hPJr uy
<br />rrtucrurc. p .,ro its issuane, ahorcquncs rhc mrltonr lor such ricrnir ro fiL! sisncd srarcftor rhll h.or ihc is li.cnwl NrsuMt
<br />lo lhc lmlisioDs ot thc conlmclr's Li.c.rd L.p (Ch,pro 9. conmcmin8 wirh scction ?frro or Divhion I ofrhc Bu\inc$ and
<br />Pn,fcssbns Codc) or lh ncorshc ir€ic,ry,t lhcrcton.ndlne hosis nxlnc rllcscd crc.lllion Any !i,,ldt,norsdri,r70:115 by rny
<br />appli.rnr fu a ri.mir suhF.rx rhc trmlicsnr ro rcivil!.nelryofnornE crhDn riv. hxndrcd doll,rs ( $5m)
<br />-1.
<br />.s owmr of lhc loFny. or nry cnplorecs wirh wtrgcs N rhct nnc clarpcnsnr ion. rill do lh. sork 0d Ihc $tr@ i\ nor
<br />inrc e.l or oltcrcd ior slc (Ss.70.14, Busirrc$ and Pmlt$ions Codc: Thr Conincrois l-i.cnr tjw rk c\ nor {rply ro M o{ncr oI
<br />rhc |)R)p.dy *b brilds ur inumrcs rtrmn. dld who dds skb wo hnn\.lforhfi*lforlhmu8hhnorhcrowtrcmDloyccs.
<br />rrovidcd rhit such impn,EnEnBaE ml inlcdcn or ofr.rcd ror slc.ll ho*cvcr. rhc huikliry or i,rymrcmnt isFnwnhin,'ft Fr
<br />nf comtlcriotr, thc Own& Buildtr Nill haw thc hurdcn of pR)ving rhd h. or shc dil nor huild or nq,mrc thc lmlrny for rhc lrUtlnr o,
<br />-1.
<br />a\osrcrollhc pro!.ny.oflrexclusivclyconlructins wirh li.cnsLic. rrcron lo conntud rhc In+d {sc.. rol.4. Bu$ncss
<br />,trd [h,l6sim Codc: Thc Conta.ror's Liccn{ Law do.\ nor applr ro owicroftrotdyqhobuildsorimprcvcsrhcr.otr.
<br />sntl qho co m$ lor such r)Dlccts *ir h a Conlm.bn, tccn\cd rurru!trr
<br />'o
<br />rhc (.onIncroi s Liccn{ l3s)
<br />-l
<br />anexcmpl unler Sdion-. B. & P.C. tu thh rco$.
<br />D6lr: Oen.r
<br />u!.)trtrIBiil0N$Nlrl]l!)N
<br />DECLA.EAI]AN
<br />I hd.hyrlrirnrndcrn Mlrtof ncrjuryon.orrhcf{'lk,rn,gdc.!rrrri,)n\:
<br />I hrve dd w ill 'tui dn a CcnitLarc of Con*nr ro S.lt lnrurc frr $qkc* conF.sdrion, $ ptuvidcd for by Sccrion lT0O oi rhc
<br />ljbor Code. ror the F.rforronce oI rh. sort for rhi.h lhc pcrmil is issucd
<br />*J hd r anJ s
<br />'
<br />ll 'hddn u rtrr.h' . rn,pcn\Jrr ' 'n\urr
<br />ncc, as requncd by s..rn r](]o of lhc Lahor Code. lot rhc Fcnbnurcc or
<br />0hc wnrk l,{ whtrh,hF Frm r\.s$d M, wur tcF' o' il.n\Jrtr.n 'n\ur.n! c ..'rn JJrl Fl'c ) trunficr trc
<br />,41 (^1^uJ I; uu <?5 9t<tr 1f (o
<br />co/l //
<br />{-,ccrliry thal in lhc pcrioflMncc oithc solk for which thh rcmir is nsucd- I shall n.l cmploy lny pcr(,n in rny mni.r
<br />s N b h...nr suh,..r b rhc wofl.6 c.nrFnsdion ldws .f C,lif(trii{ nid rg(r rhd ilI should trcoflE ruhiu Iorhc
<br />workc co'hnns,rionpmvni.is.fSNrion.lT(X)ofrh.IlhrC.dc.l\hrll,fonhwirhco,nflywirhthoctrovisions.
<br />W]\RNINC: frilure k, surc wortcn comp.trsotm .ovcr.!c 'i unhwlnr. !trd shrll cnrploycr lo si'ninrl p.irlrics rod
<br />li.n. &DIBC\ as p(iidcd ftn rhccivil fincs up lo nrc hundrcd lhousand dolh^ l:rloo.(xD). i';:::ry&/E:
<br />thcrbr,fllrmund.rr.nrhyorp.rjuryrharIanli.cnsdund.rpolisnrofChrDl$9(commmir8qilhScclion7m0)otDivisionl
<br />of rhc Burituss lnd Pmfcs\ions Codc, a.d or, liccnsc is in full nr4q*rclis.-r.
<br />h :o ) c/)t D 2 n7a(./
<br />4
<br />AITLII NLDICLAAAIION
<br />I lEdryrlli uMcrFnrlryol l)crruryotrcol il[ follownrA dL\ldarions:
<br />Dcnx,lihon Pcnnirs \bc{o\ Norifi.dridn Fcd$rlR.aularion\ (Tirtc t0. Pdn6)
<br />Rcquncd bxcrol Noriir{60
<br />I crnifyrtur rhc icd.rircgdhri)n\ rgrli.E a\hl{o\ r.treulrr. nor rpplicr$l. b rh,s pn,j.cr
<br />)(ccnify rhd I hair.cd rh$ trFplicnrion lsre ro.onDly*irh rll Ciryand Counry
<br />ns oi'hn ciry and c,unr, t c suFrrhc-*,"q1'1/6.rdiMtr.cs nd SrJrc Lr$\ rlrr
<br />nh,vc rdrn,nd pn)pcnyl{n i
<br />Applicni or AFcnl SignotuE
<br />(L ,t(k
<br />I
<br />Set Backs
<br />UFER Ground
<br />Roof Sheathinq
<br />Flood Zone Certif .
<br />I hcEby affirn undcr IEMlly of p€rjury lhal rlss k s snstdclion LndinS a8cflcy lor thc l]crfomncc ol lh. wotl foi qhich lhis Frnir Lc
<br />nsucd (SN 1097, Ci!. C.).
<br />trnderl \un'c
<br />-
<br />titrd.r'. Addr*
<br />b
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