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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BtnI,DER T}IiLCARATtON
<br />I hcrcby rmrn tndd Fn,lr! oi ncrjury rhsl I a cxtnrlr rtunr ihc Conlnctn\' Li.cnsc trs lir lhc rolrowinB rcasn (Scc 70.11 5
<br />Busin.\s n.d Piolcqsion arodc): Any Cily or Cou.ly shkh requits I p.m1ii b con{ru.l alrcr. intmvc. dcm'lish ur rcIUt rnv
<br />so.rxn, rriorro nr issuucc. ds. r.quircs rhc lpllic$t lhr such li.rnrir tu filca sisncd ndctrrnr rhnr hcot rhc t li.cn{d Nnurnt
<br />r, rhd ln)lisnrs of rhc co racioi s l-iccn*d hw ( cl[plcr 9- conrnt'kiD8 wirh sccrion ?fiD of Divisiotr 3 ol !h. B rim(! itrd
<br />Pft)lcsions Codc ) or I hrr lior\hc iscxcmPl lhcrcfronand rhcbav\ ror rhc lllcscdcrc !flk Anv viol(ionorsNrio!?0115 t', uv
<br />rpnlidtrr fu a p..nrir \ubj<{B Ihc (ppliclnl n, a civil Fnilry oi not mrc lhln fivc hundrcd dollrs (S5U))
<br />-1.
<br />!s own$ or rhc proFny. (n nry cnrpk,tes wirlr *agcs ,s thcn sh coorp.trr,rn r. will do tlE work dd rhc slruclurc is ftn
<br />i' . dcrl or ollced ltr Blc lsr ?0.1.1. Bxsincss $d Pitb$io!\ Cod. Th. Cotrlrncnr's l-iccn\c Las dnes nor lPpl, ru ai 'smr '[rhcpmf.ny who hurlds or imporcs rhbn, url stp df,s su.h s(fi hinrclfot h.r{llor rhR)t8h hs or her o*n cnllovces.
<br />proridcd rhrr su.h Lntrcrcnrds m ,xn i,ncidrd or ofic8l lor eh If. ho*.\cr. rhc t{iltliru .t n rrorcrEd t $!1 wirhin orc rc{
<br />ofcon]Ihti,n. llE Oqncr Buikls *ill harc lnc hrdcn of Imvins iru hc or shc did nol hxild or inPmw lhc lmFiv ror lhc luqxrc oi
<br />l- nsotrncrolrhcp'olr ry. n cx.lusivclycotrkrcrin!wirhli.cr\cdconrrkn\k,.otr{ru.rlhcptrrc.r(Sc.7(}{ l,u\i"ts
<br />r l Pr,lasssr Codc rhc ConkKtr'\ l-i.ctrsc Lawdocs nor anrlyk) t owicroinroP{nrwhohuild\.ri,nprovdsrhcr.on.
<br />rnd who onrhck t(tr ru.h l,tulccls silh r Contr.k,(, li..rNcd Puruul trrh.cont..ttr i Licctr\c kw)
<br />l x cr.n,t, u dcr Sc.r
<br />lrl)BtrEBfla[lfENsnlroa
<br />DrltA.EdullN
<br />I hcrchyr'nnoid.rIf.hrolpcrjuryoncorrhcrdlo*in8d..ldiriqr(,
<br />I hive und aill,uinrlinaCenificnrcofCodsenllo Sclf-lnsurc for Norkd. comP.nsdion, s pt)vidcd lbrbvSccrionlT00ol thc
<br />Lahor Gde, ror rhc FrlollMa of lh€ wol} to, {hich rhc plmil is isucd.
<br />-lhsvca.dwilrtrmi
<br />uin *ortc6'.ompe.s nrn insurarcc. $ rcqutcd by s.d ion ]700 oa rh. tabor clodc, ior 'lt
<br />pcrt'rmn:' af
<br />rh. wor* fttrwhthlhisrcmir is Lrsucn. My workcr' mmpcnsarion insurnncc cMicr ud p.li.y numb.r ec:
<br />Policy Numh.r
<br />-EiPircs
<br />-l
<br />ccniayrhor i.rhc p.rfoirMnLrol thc *oI\ ior whihrhi( ncrnir is irstd.l \hrll nor cn{lovanr!.6otr in invm!nm.
<br />v, * b hd)nr subrc.l lo lhc *ortrc co'nlE.smion laws or C.lifomir, aid a8rcc thlr il I \k,uld h..om subjccr b rhc
<br />*ork.d oml'.trsrrion pmlGn,ns or s..lion 3?(x) oi rh. likn Cdlc, , stu|l. fon hsirh conply wirh rhos Prrvisn,nr.
<br />WARNINO: Failur. t. surc workcr' conD.n\ari r .ortaec is utrlaNtul and sholl subr.r cmrL)$ ro oinrinal lrMlri:r and
<br />.ivil ftrrs ur k'.N htrtrdrcd rhou\rnd dollar lm.O00). ir diriotr k, rhc.o(
<br />:"-7J;;J*',"'-
<br />I2r!!.tts[l]l1!
<br />I h.rcby 0finm undc! rcnalryoipcriury lhd I am lietst undcr F.vhi.n oiChit'ic.9 (comtr i.8 wilh Sdion 7000) ol Divhion l
<br />of ibe Bu{inc,s dnd PolcssiorN Codd. dxi
<br />'ny
<br />li.cn* is in tull lorce arxl crltct
<br />-la o6
<br />I h.rchyrfinmu cr |tnrlryor,'.riury I
<br />i{sucd (sc. :ll)e7- Civ. C )
<br />rhcd i\ a .odarrucrion lcndirs Bs.tuy roi Ihc Pcrt'ormamc or rh. w..k
<br />l.nd' ''\ NJi.^
<br />-
<br />knd.r'q Addre\s
<br />-
<br />ATIUI3NLIIIj.LdNAIIQN
<br />I IEE'by ilmuntlcr lconlry ol p.rjMy onc olrhc f{'lk'wnr! dc.l*rrions
<br />Drnx,lni(,n Pc n s Asbcsr.r N.rificrrion f.dcml Rcaul!rions (Tiilc40. Pan6)
<br />RrquirdtrrcroiNolific i,nr
<br />nr,xrmrion is.onr.^t llsd ro$m0ly wirh lll Ciry.nd Coutrly
<br />xurh{rrc rcpr!scnrrriv.s ofrhi\ Ciryrnd Coui
<br />""-..T{
<br />Set Backs /?
<br />Forms/Steel/Holdowns a/2//ts -dt'//ac )
<br />Ereclion Pads /1,
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulalion
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lns u lation/E n erg y
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />Handicap Req b/>/lo -fl"12 rr.€01
<br />Deputy Final Reporl
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />0/h//0 flw\A'ttA
<br />Certif icate of Occupancy vs
<br />Notes, Remarks, Etc.
<br />I
<br />I ccnil'yrh{ rhc li\t.rrl rcEUln.otrs rcBo in8 ash.sos nrc ior intli. hi. k) rhrs pr.t er.
<br />T-Bar
<br />FINAL
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