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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ()1{Nf R IIUII-DI'R DI:LCARA'TION
<br />I hcrcby arit undcr Fnrlry or l).rjury ihd I m.xcnU lilnr lhc O,nkrcbn l-iccn{ Ijw ro. rhc ,olLsin! rcavnr (s..70.11 5
<br />Br\inc* aid Pn,f.$iotr Codc) Ary Cily or Counry uht[ rcquirc lf,rmn kr con{rud. lllcr. imP(,vc, dcnnrli(h ,tr Elsir in,
<br />nrudurc. priorro ns issulncc- aho rcquie\ rh. dppli.im ln such lEnnil lo filc ! \istrud nllciMr rh.r hc or sh. n lic..\cd IrtrAxrnr
<br />b rhc F)virn N urrhr Contracrolr Liccnrd Low (Chupicr r)- Connnctunr! wirI Secrion 7Ux) oi Diri\ion ] orthc Busirr$ and
<br />PnrlsionsCodc)orthol hcorsh. iscr.mpr rhcrclio and rhc bari! for thc allcscd c(cnPrbn Adyvn,hrnnrolscrtnt'10:rl5hydy
<br />!pl)licanrn, r pcmir suhjcc(rhc lt)fli.anrrorcivilpcnalryolnornrrcrhanfivchundrdldollrs(3500)
<br />l. is owNr .l Ihc pm|Eny, or my cnulolccs lirh wascs ar lhct vnc conPcNdirnr. $ ill do lh. solt u'rl rhc sdtrrE i! tror
<br />ic,xhl orofilrcd lor $k (Sa 7olt. Brsit\said Pmics\i{'nsc( c: Ttu Contrctr's Liccnsc l iw do.s nor amly ro ,n owns or
<br />rhcfmFny who huild\ or nrvlx*r\ rlrcr6|n. lnd who ne\ su(n mrl hi'n{lfor lB\clfor rhmueh hh ot hcr osn cmfhyccs.
<br />p'1,vticd rhorruch nry(rcnf,hn m kn inrcnd.d oroffcrcd fn s0lc ll hoscq rhc buildir8 or i'npbtnEnl is sokl sirhi'r .trc ,ttrr
<br />ol.oruhbn. ilEOwncr Builicr *ill hrvc rhc burdcn.rpft,!i',8 rhd h. or shc dil ft,1tloild or in{8nt rhc lf)ltny {ir rhc PUrIn{ Dl
<br />-1.
<br />!so*ncrotrhcnxrpory, nmcx.lu$vclr.onrn.r rB wirh li.ctrsrd .od ra.tn n, .oNru.r rhc roisr (Scc 7Or4, Bunncss
<br />rl Pt fssi Codc Thc(1,ntmcktr s L.iccnsc l nw docs nor rlplyt) rtrowns olfropcrry*ho buiktsor nnrrovc\ rhcr.on-
<br />and *ho conrrichtur s..hfmrcriwirha Co roch(I liccn*d ptrlunr !) rhc Conuicrn.s Liccnsc ltrtw)
<br />I r r.xc t, trDdcr Sccl
<br />Dar.: Ovner
<br />woR(rRs' colllPFNsaT(lN
<br />DECLABAIIAd
<br />I hcrch, arfirn trndci Fnaxy.rFrjuryonc ollhc rbllouin8 dcclurarion\:
<br />Ihnvcmd*illnDinrrin.CcnificllcofConscnrloSclflnslrctorsorkcr'.omPcns.liotr.!rFovnbdftrbys.ctionlT0Oo,rhc
<br />Lahr Codc, l'or rh. p.rrornme or rhc aork for *hich lhc pcrmir h h$.d
<br />I lrrr.nd willnrainrain *o.kcrr compeor ion insurrmc. a\ rcquitodhyScctio.lTl)OnfrhclahorCodc,lorrhcpcrfomumcof
<br />rl[ *ork for which lhh Ernril is hstcd My workus .onD.isrln rtrri.cc.{tricr andF,licy iu'nbddc:
<br />t-lo0 N{q.
<br />0cot31vqD3 /0,/.,,/t*
<br />I ccnify rh.r in thc p.rfonmncc oirlr *ork lbr which rhn pcrmir i\ tsucd.l drll trol cnrploy ony P.^on i. any nBtrncr
<br />$ $ to bcqnm subjccl kr lic *o*r^ drnp.is.r ir'n liws .l Caliloiflia. ind agB rlEr it I \hould bNonE suhr..l ro rhc
<br />workcF conlPctr\aii.npft,vhionsolSccriotr3T0OofrhcLlhtrCoic.lsh l. fonh*irh .omtly wirh thoc pnvili.ns
<br />W RNIN(;: Farlurc to {cu!c workcrs cor.pcn\arion cortErc n unLqtnl. aM sh.ll suhjccl !n cnrdoy& to Lri,ninul Pemlrics md
<br />civil fii.s tp io.ic hnndnd Ihous.nd dollan lS|OO.0O0). ryodd!tr,tr r, rhr (u{ or\o rtf,trqrion. tlln rc. r<,,mvitlcd l(,r nE
<br />:::",-
<br />- i ;Ei ; - T::,,-T:..+,.{ffi J,,-. a, e t
<br />D[gJl uoN
<br />I hcEby rlfinn hdcr Fmxy ol Frltrrylh linlicc.scdu cr flovisi(r oi Clrrpi& 9 (connrm.ing wiih Sccrbn 70(]0 of DNision 3
<br />of rhc Businc\s ud Prorcsion\Conc, and 'nyli.cns. h ir tull lbrcc ffil cilccr
<br />AC /a/
<br />,,.,, s /22//tr o/ey a-ra C ty
<br />II]NIIBI]SIONTENDIIG.AGI'III
<br />I h.Eby atfirm undcr Fuhrorpojutyrh,t rhcrc ir t onsrudion lcndins uccn.y ror rh. pdinirercc olrhc sork td which rhis lfrmit is
<br />issu.d (Sec l097,Ci!. C )
<br />A.ITIICAILD&CLAMIION
<br />I trn$t Jfm u ndcr pcnrllyofpcrjury od ofrh.lolk,winB ddlnnii(,n\
<br />D. i,lirt PcnntsAsh.sros Notifierion Fcdcral R.Errlnrion\ (Tirle 4{}, Pd6)
<br />Rcquncd Lcrrer oi Nolili.att n
<br />I ccn'fyrhrr rhu Ldcral rcBUhri,)ns rcstelirg trshcios rcnDlrl rr. urimli.0blc ro,ht Irrl$r
<br />l.cdiiythd Ihrverc lhhapplic i,,ndd (arc rhdrhc rtx,vr iironnnlotr is cotrccr lJsreio.o.flywirhlllCirylndCoh'y
<br />ordiirnccs md Srd.h*\ rclrri.g
<br />rtx,vc nrnlioncd pmpcny nn
<br />,\pplicnnl or ,\Aenl SiAtrstu
<br />Pemile mn€ (Drintl:/"lrr
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsu lation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />[/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Cefiif
<br />/olu//8 e Yt4,17'14,,/,r,2-
<br />Certilicate ol Occupancy
<br />Notes, Remarks, Etc
<br />ID/SIG.COMMENTS
<br />FINAL
<br />Lr.dc, r\rn.:-
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