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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OIVNER AUILDER DI]I,CAR TION
<br />I hcrchy rtfinn uidcr pcnalry or Frjury thr I dn cxcn lf,r rhcCo rrd,'n l-iccn\c L{ tur rh.ldlowirg rcav'n 1scc.70ll5
<br />Bu\inc*,ndPturcs\bnCo{c):ADyCir}orCounlyw[].hrcqunc\rt^-nnilk'.oniru.r.rhcr.nnPolc,dcmolisl.r(EnMy
<br />!n.!urc, prior ro ils hsuincc,0ko rcquiEs lhc eplicnnl Ior $ch |fnnn b fibi ngncd srrctrtfi lhrr hcor shc i\ i.c \rd lusurnr
<br />t, rhc p vntun\ of rhc Cotrta.lofs Liccnrd L.w lch$rcr 9, Con ncncing wirh S.crn,n 7UD of Divisi(r:l ollh.lldsincs rid
<br />Proic$bns Codc)orrhlr hcorshe iscrenrpr rhcrerio'natulrhc hrsi\ Lrthr lllctcd cxcnDrion AnyvioLrnnrorsc.ri(rr70:ll5hyrny
<br />rpplicanr f{n rl.mir lubjc.rsihc +llicrnr Io a.ivilpc.rhyolnor nnrclhln iivc htrndrdJ dolln^($5m)
<br />I. as oqn$ or thc l,otcdy. or my cnployces rilh ulscs !s rhcir $k .$rp..urion, *ill do lnc wolt md lhc smnm is nor
<br />irtc cn oroficred lor sk (Sa.7014. Busincsand Pofcssion\ Gdc: Thc Cont0doir Liccns L€* docs nor atply h ,n owN ol'
<br />rhcF)r.ny who bxilds or inpmvcs thcNn- od *h. des such sork him*ll or hc*clf or rhtuuAh his ! h.r .8n cmpk,yc.\.
<br />providcd riar su.h Lnpokftnh m nor int.frkxl or off.ral i(/ snL lt: k'wcrr. rhc hoildiig or inWoRnE is $ld wirhin ,,nc )t.tr
<br />ofco.{lction. thc Owncr Buiuq willhrre rhc budcn or pmvin8 rh, rr or \hc dil mt h'ild oi inri,,ovc t pDFi, n, dE N4!s of
<br />-1.!sosncrolthepopcnt-onrcx.lu\ivcly.ontrcririgwirhlicctrgdconractosrocondrucrrtrFic.r(Sc.7(s.r.Burncsa'rd Asfsssn Codcr Th.Conlrflols Liccnsetjwdoe\ nor lptlrro anown.r of[opcnrwho huikls orimprovcs rhcr.on.
<br />and who conrEcls for such ttujdrs wilh r co.rn.rorls) li..n$J puruanl h rhc coik&tr's L{ctrs tjw).
<br />-l
<br />mcrcnpr undcr sdrio. .a &PC forlhnrclv,n
<br />D . own..
<br />w()RxnRs c()ilP[Ns TloN
<br />DECIAIA]ION
<br />I hcrchy rffi rm undcr p.nrlryof pdluryoR olrhc followin8 dcclamri.ns
<br />-lharcud$illroinraiorC€dinrreofclnr*nrbs.lf-lnsurcforeorkcr'co{.n\rrn,n.a\rn,vidcdtubySccrionlToOolrhcLnhr Codc, for rhc lcrlorrome oi rhc sork fr shich rhc J)cmir ir issucd
<br />_l hau and will tui.raio sortcie .onpctrsdion iNnramc. as rcquiri hy S(rn,n .l7m or rhc Labor Codc. nx rhc ltmnfuRc ol
<br />rh. $.* f.r which rhh p.mir is issd. My workcn con{rcnsor ion in\!nn( cffihr dd Jblicy nu mbcr ec
<br />2- t.,r i c [,r,
<br />\Q c\C) jOO 1 oCJ t ,.r tttt-](tt
<br />I ccdiry rhar in rhe p.rfornEne olthc work i.r which rhi\ ri.onir is issucd. I sh.ll nor cmlLy any !.con in rny matrm!
<br />e asro trconE sbjcd ro rh. $o&ds .onpcn$rion lrwsotcalifornii. and !3rcc rhd irI rhouki b.com subjd lo ltr
<br />eorkc's'.o.rFnsarionfiovkionsofScclionl?0OoflhchtorCodc,tsiall,tnnhwirh.lmplywirhlhnspolhn'ns
<br />WARNINC: leilurc to scuc sorkc^ compeosarion cover.sc 's un)rnrur. rnd lholl suhFct an cn'tl,,ytr ro diminrl lcMlris and
<br />civil fincs up lo orc hudrcd rhousand dolh^ (slm.mor
<br />'n iJd tr{r I' rhc con .l (ornncnrnnNrtug6 s frovidcd lor rhc
<br />'""""'.,Td;Ifl:?' ^,,;fi;ffinuuN
<br />DECIdEAIIOJ
<br />I h.(by rrfirm und$ p.Mlly of pcrjury th.l I am lccnsd undcr pmvision orChirrd 9 (comnEncing uirh ssrion 701)0) orDivhtu 3
<br />ol rhc 8usircs,nd Poa.srion\ Codc. )d mylic.nsc k in tul1fore lnd cilccr
<br />r"-* "** C- 3Q a-t\
<br />N64/14l tS< co nc,o. (?o., a-\ Tto.rt, ^'.^ /nu\t)
<br />coNlirru(:uoNLErDlx$-dtiltill
<br />I hcrhy rrfiri lndcr p.n,lry.rpcrjuryrhal thcrc n ! o.slructbn lcndira trg.icy rrtr rhc Pd ronrDRT oirh. wolk lar $hr.h rhit F mn n
<br />i$ued (Scc. l(E7. Civ C )
<br />dtPUTTINLDIILA.BAUaI
<br />llrfthy dJIr undcr p.trrlry orpcrjuy onc.irhc iollo*ins dc.hrarn,ns:
<br />Dc'!olirnrn Pcrnrir\ Ash.sos Norifmriotr frdcral RcAulrtri rs (lillc40. Pa ())
<br />R.qunrJ Lc(.rorNohll.{n r
<br />l.dlililhol lhc lcdcrul 'cSUhri(,n\
<br />rgtmlin! r\ll{osrctrbvrlnrc mrrPflict6lc n, rhi\ |n)rocr
<br />_l (nitr rhar I hdvc.ed rhh applic*ion turd salc llml lhc ab.vc in[i otr n.drc.r lr&Lrh.ondy trilh rll( iry 0 ((ndy
<br />ordimn.c\ "trd
<br />Srrrc ljws tolding ro building consrfl.tion..frlhcrchylur Tc rctro{ rnrivcsolthL! Cirynr,l(i'Ltrr!rrcnrc' trfo lh.
<br />rhovc nrc nnrcd ptupcnylor in
<br />AlDliconl or Agcnl Signnluml It, !v\Oa-/!:LtV
<br />"*.n**-"rrn*r, x- L'l tL[], W\,! rs4.
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsu lation I
<br />Roof Sheathinq ,/)try tt]|r/
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lr/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL 412.,$7,i,ln*xL fi-D)
<br />Cerlilicate ol Occu n
<br />Notes, Remarks, Etc.
<br />_.,
<br />Erection Pads
<br />Shear Wall
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