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BUILDING- INSPECTOH RECORD
<br />SITE.WOHK DATE COMMENTS OWNER BUILDER DELCARATION
<br />I hcrchy rlfirn undcr lcn0hy nl pcrjury rhat I m exenr/ imm ihc Conlncrom l-iccn\.ltr* f{x rh. r.U.wire rcastr (Scc.70ll.5
<br />Bu\incsr rn<l Pioic$inn Cdc): Any Ciry or Counly which rcquircs a Fnlir k,.onsrruci. Jbi nnprovc, dcnmlnh or rcFir rn,
<br />{ru.rorc. prin lo i( i\suancc, also r.quncs lhc.mlicrnl fd su.hr.nnir to lilc r skncd storcnrnr lhnrhcorrhc il lienscd pu6x. r
<br />r. rh. F,viln,n\ ol rh. Conta.roCr l-ttnrcd Uw (Chrprcr 9. G,fr'nci.ine wnh Sccrion 7Ux) ol Division .1 o{ rhc Btr\incs and
<br />Pmfc$ions Codc)orrh.r lEorshc hcrc.{'t rhcrcfromnnd rhc hNt lbr rhc rllescd.rcfiprion Anyvnnordnofs&1ion701l 5bytrry
<br />appliconr ror a pcmir suhjcck rhc rpplicanr trncieilpcnalryotnor h.r.rhrn rivc hundi.d dollrs($s(n)
<br />-1..s
<br />owncr ol thc DmIEny. or my c ploles wilh wa8csnslhen $t.ompcn"lrioi. Nilldo rlr *dk tlrh.{n.turctfln
<br />inrcdsl or ottcrcd lbr $lc ( SE.' ?044, Bxsi'r.$ lnd k)f.$ioas Codc 'I h. Conku.tor's Lic.tr* tjw dms rcr lpnly ro an os ncr ot
<br />rhc fmicny who htrikls or inD(Nls rhcsr lnd *ho docs sch mrk hirnsclior hcrcll or rhn,ugh his.r h.rown cniDloyccs-
<br />pmvidcd rhar such impft,Etum\ m mr inrcndul or ofi.nJ ntr sb Il h,s.vc., th. ttrildin8 or i.n0rorcrrnr is $kl qirhin om )td
<br />ot co q,lcthn. thc owmr auildq will h.rc rhc hoden of rrolins lhal h€ or \l'a did n,l hxild or i'qmr. lhc lmFiy fot lfu Nqrc oi
<br />Lr\owncrolrhcpn,pcn!,rncxclo\ivcltcotr.riigsnhli.rnscdconract.rsroonnnrcrrh.Ir+.rlScc7o.1J.B!\i,'c$
<br />lnn Pnits{onc.dcr'r'hc Conlracroir l.iccnsc l.aw docs r.llaplyro rio*ncr.t[or. y wh,) 6uilds or i'nPov$ rhcrcotr.
<br />,nd who co tk( ftlr such pbjccrs wnh r C(dhft,ns) li..rscd lunuiflr ro rhc (bnrmkn s Liccnsc ltrw)
<br />I rmcrcnpr undcr Sccrion . B. & P.C. for thn rcason
<br />Doter Owre.
<br />u:QltrDtsI]!Quf!!SA-ll9!ltrl:lA&trIlN
<br />I hcrcby nflnD unilcller.liyollcrjuryonc otrhc l'ollowin3 dcclarlrion\
<br />-lharc0dwillnuinrlinaCcnifElrcorCon\cnlroSelllnsurcior*o'ko!.orlcnernnr,,\!revidcdlnr$ySLtrionlTtrotrhcLihor Codc, ior lhc !fiforromc of thc qork lorwhich lhe pcnnir is hsrcd
<br />_l hrvc rndNillnui 3in *orkcFi conrncn\alion in\!rrn.c. a\ r.rtuircJ hySccrnnlTUlofrhc La&r (i)dc. irrrlE |xrtn kcol
<br />I rn{,cd Nlr_!or[.r\'ron]Nfl\rri,rntrn'rnrc.x'rr xi'lt)lr.!trtrrhrr rr.
<br />c<.
<br />o lti
<br />I.cdify rhar in rhc pfif.imncc.lth( wolk lor trhich lhis rcnnir h nsrcd. I lhall nor cnuloy rny lc*on in riy mmnci
<br />$ 6 b b(strE subc.r h lhe wodcr' cornpcns iu' hws nl Calir'ornia. ,id aaRc rh irI shuld b..onf, subjd loihc
<br />workcs coml'ctr$lion Drcvisi,rns ofSarion 3?OO oalhc Lahtr C{nl.- I \lnll.lanhwirh co.lltly wih thot Pruvkions
<br />WARNIN(;: Frilur k, sur. workfL.orFnsJrion.ovcr gr is utrliwtul. d sh3ll suhFrl an cDpk,ycr h dnninrl |fMlrics rnd
<br />::N'11'ry'
<br />dollrs (Sl(x).(I]o). ir ftdirion ro rh. colr oi drrugcs .\ provnlcd for lhc
<br />I hcrby dafirdundcr Fnalry.rp.rjury rhd I anr li.ctr*d und.r pmvisi(r olCh+lcr 9(connrrcncinB wilh s.cihtr 7fix)) ofDiv(ion 3
<br />of lhc Bu\ircs md Profe$ion\ Codc. ud m, liccn* i. in full fom fil cfla.r.
<br />- o qrffu
<br />I
<br />C!}NSIA!JCII!]NIE!I2I!G{iENCI
<br />I hcrcby rflirn undcr Fnalry of pcrtur! lh0l r hqc n 0 coNrrudion hnding usency tu rhe lcrformn c or rhc work rn uhi.h rhh Frn l is
<br />nsx.d iS( .1097. Civ C ).
<br />A[fucANtDEC!$duoN
<br />lffiytrUimundq pctrolty of pcrjury oic of rhc lolbwinE dccl&rioni
<br />lNnElirion Pcrnrirs-Asb.slos Nolification rcdcrrl Rcsularionr 0 nt {J- Pan6)
<br />Rcquncd tJn.r ol Nolificalion
<br />-l
<br />ccrrif, Uar rhc lcdrral,csrl,ion\ rgding a\b.{ol rr xrvxl @ iot,Iplklhlc ro lhn tNj.rt.
<br />/4-d,1r,hd I IrN. *,n $^ Jntl crrtrnr i' q,ic'hrlihcnh,v. nrronurion iscorrccr.I lsre ro comdy wirh ill cirrrnd Courly
<br />or'l'nJtuc\ rnJ Srarc Li*s rulr!'ne r. bu'ldh8.on{rucrrr. dnd hcrcby iuilMizc rcDrc\cnrarivcs ofrhi Ciry Md Countylo cnlcr uron rh.
<br />rh,v. mtrri,)ncd nmFny ftn ln\Fcri,,n
<br />Applicn o.AEenlSi!tr{lum ,,,,Yll ' r',:
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />Subf loor/VenVl nsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq 5/r:v//b 5.W ia.c€)-]+*r
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />l\4aso n ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Reporl
<br />Flood Zone Certil.
<br />FINAL I i-/? -/a-tJeJ>*{d/)
<br />Certificate ol Occupancy
<br />Noles , Remarks, Etc.
<br />ID/SIG.
<br />&,.o-
<br />SLAB Floor
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