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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.OWNER AUIDER DELCARA'IION
<br />I hcrcby rmnn undcr i.nrlry (,r Frjxry rh,r I anr cxcnrpr tm.n rhe ConrracnF Licci{ hw for rhe foll.sins rc,\on (s*?0.11t
<br />lusinc$ a&i Prclcssion Codc): Atry Cii, or c.umy *hich rqotcs , p.rmir k, on{tu.r. alrft, nntlrovc. dcmohh or rcnan ..
<br />('acl!,c, pri'! ro ils issurmc. al\o rcquncs lhcap0licont lor such |Ermit lo filcr si8ncd nalcmnl lhrr h€o! shc h liccnrd purn'anr
<br />ro rhc pmvisiotrs ofltr Conkrclofs l-iccnscd Ijw (Chnnru 9. Co.nncncing wirh Sc.ri.i 7fill of Divhiotr :l ofrhc Busincss rnd
<br />Prort$ions Codc) or Ih.l h. or shc k crcn lhcrcfronrnd rh. ho\i\ ror Ihc rllde.d .rcnDrn'n Anyviol.liotrofsstionT0ll 5hrrny
<br />rprlicad nr a pemrir suhj(\ rhc applicanlro.civiln.nrllyol nol nn.dhar rivc nundrcddollars (S5OO)
<br />-1.
<br />as owmr or 'ft
<br />ptup.dy. or my c,nployrcr *irh w{tcs .s 'lrn sb .oq).nsrr ion. will do Itr wrk 0 thcatu1wn mr
<br />inicd.n or oflcrcd for slc (Ss '7014. Busirc$ md Profe$ir)nr Cnlc Th. (nntr(lrt Licctr* L.w des not apdy to an o$ncr ol
<br />lic nmEny who brilds or nllr,mrcs rh.Nn. .rxi wts dG skh *,lt hn$clf ur hf*li .r rhtuush hil or hn own cmDloyccs-
<br />,rovid.d rhar ruch imlmkft.B d mr inrcndci orofic(n fo' {t.l[ ho*tti rlr hrildinA o, nq'mlrmnr is rH wirhinok ]rd
<br />dr.rnnphrbn, rlE Owmr Bdls will hlvc rtr hurdq of pmvirythr hcorshcdid ftx bliLl or in{,ro!c rnc pmFny for rhc pnqnt or
<br />_1.!sosncrotrhcfopcny,or!cxcl$ivcly.o.r0dirgenhli.cn*d.oru.tunfuon.rfl.rrtEl)ror.r(Scc.701,1.Bunnc$
<br />,nd Pftf*sion Gdc: Th. ComBcrtr s Li&ns. Ln{ dms nor ryply ro rn owncr ofln,pcny*ho builds.r imtovcs rhcrcon.
<br />and who .onlacts for sEh lmjccrs wnh a Gn Bdon s) liccnsd pxrsunr ro rh. (i)ntdclois Li.cnsc t w )
<br />-l
<br />mcxcn+l u.dcr Sdio. .B &PC turrhisr.i\,i
<br />I1af,&;f,L.(jaUl1illi [Ia!
<br />Dr:!,:Li-8 .r!)!
<br />I hcrchy rllir utr .r t)c nlryol t)c,ltriy. ..l rhc l('11,,{ing,lc.h'rrnn}
<br />I havc mdwill nrnn ir rCcnifi. rc olCo \cnr k'Scllln\uR lin wor[.^ compci\ ridr. r\ pn,lrdcd f(tr brSc.ri(n]Tmof rhc
<br />hlitrcodc. for rhc pcrformanccofrhc {u[ nn Niichrhc psD I i\ i\rucd
<br />/>lhi\c.'ndxrllrr'.'d*,rlc6'('{nlrNrltrfln.urdcc. r.quir.dbySLrri(r:l7U).lthcLdbdGrdc.lnrrlrcpcrtonnrnccoi
<br />thc *ork lorshi.hrhis Nnnil ir i$ucd Myworkcis ..trrnci\rrnr ln{trd.c .rricrukl lmli.y nunrhc, nc:
<br />l4ic R-,"1J
<br />12\\358 1-7 5t
<br />-l
<br />ccniiythal in rh. Frloirumc of r hc work for *hi.h rhi\ p.rnrir ir hsucd,I shrllnol cmfloyanypcrson in.ny monner
<br />$ x ro t&-ft suhJecr ro rh. *orlcr' onrpenerion hw\ of c_llifomia. and lsrcc thul if I \houi bccom slbrcr ro thc
<br />workc* o[pcnsalion pnlnionr ofS.clion ]TO0 ol rhc litnr Codc- l shlll nrnhwirhcomrly ei'h rho* pt6!iri.n\.
<br />WAnNNG: Fdlurc ro sur. workcs .onpc.sdri(nr cov.asc i\ unl,wrul. Md shll subicr .n cmplo)rr lo nin nal rEnahies n.d
<br />civil fincs up ro onc hundEd rhouend dollrs (SI00,0O0), in addirn,n ro (hc.o( of.onD.ntalnnr. darugcs rs providcd for lnc
<br />Scction 10?6 .f rhc tf,bo. Codc. imcesl Md . omr'\ fft\
<br />,,,", Sloltl noor-^, rk{E@
<br />r rcEl!*?rr[\l.t6cr0R
<br />DECIAMIIQN
<br />I hcrcby afirm undcr pcn.h, of rerrury rhat I !m lieNad undcr Dmvision olChnprcr 9(.onnEncina wirt Sccii,n 7fiXD orDivhlr.]
<br />ol lhc Busims and Pmfcssions Cdc. nnd my licctr* is in lull fd.c rnd c((r
<br />B lorr gsL
<br />5 'ltb
<br />{a$uf,ltcuatirElllllcac[M;r
<br />I hceby alfifln uM.r Fn.hyofa.lury rhar th.rc h a.onsfl.rinr hndi'r8 rtcky rrtr rhc p.rfornmNc olthc qolk for rhich rhh pcrmi n
<br />issu.d(S.c :1097. Civ C.)
<br />-l
<br />ccniiithnl rlr ttdcrrl rcsuld ions rcr{ding r$((.s rc Nul/rc n.lrnflr.hlc Io rhh !roF.-^r.
<br />?A cMily rhd I hdc Erd rhi\ rpdlcari(,n and drrc rhar rhc lhvc nronuri,{ s corc.r I nFcc r, .oqry w ih .ll ( rr y rnd L:nunly
<br />ordimnr.s Md Srrre b$s rcLrin8 b boildin! coontucri{,!- md h.!.6v aurhorirc reprcsdntdivc! ofrhh Ciry Md Counryro cnrs uton rhc
<br />,hovc mcnlioncd popcny for ir\tr.cri,n l]uqr\cr
<br />,\pplic,nl nr .'\s.nr Si!n,1,'rr
<br />AlorrU
<br />5
<br />Forms/Steel/Holdowns
<br />Ereclion Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing ,/l/E ,->1 tf-,7k9/
<br />lnsulation/Energy
<br />Drywall qrz /12 >-79 LCt ;72L*/
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Mason ty
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />De Final Re rt
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL ils l>e,VEr* g*
<br />Certilicate ol Occu pancy
<br />Notes Remarks Etc.
<br />COMMENTS
<br />Set Backs
<br /><ft
<br />AllulAlfDliclrl.8AllllN
<br />I hdc$y llm undcr !.nalr, ofFrjurt onc ofrh. f{,|k,*n,g declmrio,\
<br />I)cnxniion Pcnnits Ashcno!Norilicarn,n Ftdcrul Rcsuldtnrs(lirb,r0. l'[lo)
<br />Roqunod l.Icr ol Mrifi carnn
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