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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER AUILDAR DELCARATION
<br />I herchy {filrn undcr tcnshy ol rrjury tfial I am cxctrrt'r riom lhc G,niracnm Liccn\c ljw iar rhc tnllowing rc.$n (Scc 7031 5
<br />Businc$ nl Protc$ion Codc) An, Ciry or O,rnrt shich rcqrires a p$nil tu conslru.r, rher. imlrovc. dcmlnh nr rcNn any
<br />srru.ruc, pritr k, ns ksudD.c, aho mqutcs rhc +nlicrnr lirr such p.rn b filc. signcd srdcnEnt lhol h.or shc h liccn$d plrunl
<br />h rhc rovtions nfrh. C.ntmcrois Licenrd Ljs (Chaprcr 9. Conrmencins *irh sccrioo 70fir of Divisn,d.r .frhc Busincs and
<br />Pmfc$ioDsCodc)o!rha,hcorrhciscrcmptrhcrcim'narlrh.6osisa'nrhcallc!.d.r.nflbn.AnyvioltrlionofSslbn?03l5byany
<br />+rlic,nr roru p.rmir rubjcctslhc {,pli.,Dl (o,.ivilpcnDlryornor na,c llm livc hu trdr cd dollffi 1$500)
<br />l,rsownforrh.ItroFny.ormy€nDloyccswnh{a$sasrh.t$lr.unlcnsn.willdorh.Bon(andrhcstnIt@ismr
<br />inlc cd or orcto{ lnr saL (Sa.7014, Business ond ProLsions Co{jc: l hc o)nrroctn'r l-icery lj* doc\ n r eply to 0n owrcr or
<br />rhc pn)p.ny wh) buitd\ or inllrN.s rh.Nr- dld wh. des u-..h wor* hDsclfor hcnclfor ihmuBh hh or h.r osncnDloyccs.
<br />,rovidcd rh,r $c[ i'ntmh'mnh m mr i cnldt .r olrcEn for $L lt howcE. rhc huilding or ir{,mvcrnr is v,h *nhin otu ttt'
<br />ofconDbrion. rhc Owmr Buildc, willh& rhc trrdcn of provins rhd he or shc dA id bLiU o, nnpok lh. F,p.ny ior ttu |[rlrE ol
<br />_l. r\osncrofrhc pmpcny. !msrclu\ivelyconkactinawirh liccn\d rontJckns b co nru.r rlf, ,mjccr lSLr 7lr.l. Bu\irc\
<br />id t\r)fcs\intCodc: lhr C.nii(tn's Li.cnsc Lrs uc\norntplybxtro*trcrof| ,Nrlyshobuild\.rirnpnrvc\rhcr.oi.
<br />rnd sho .o mcrs lb. {'ch !ml..h wilh{ Conra.r,n\) liccrscd pursur n,rhc(in racntr s l-i.cd{ Ij\)
<br />I rn.rcn,[ undrr S(rio
<br />lhl( (rPnc.:
<br />lll3lili&t-llturllN$rlax
<br />DEILISAIIOI
<br />I hc'.hyrilnnun,l.r ncnrlr).f ncrJurIoN of rhc n,ll,nving drc ir rion\:
<br />-lh!!cuDdwilltuinrain!CcnillcrcorConscnrr,Sclflns!rctuw.ikcrs.ompctrelion.ostroridcdforl,yS(iionlT0oofrhtL€hor Codc. for lh€ pcrformne oI thc *ort tor *hich thc pcmn is isslcd
<br />I h,w and will mdinraD workcrs corhp.nsaliotr ihsnran.c, ns ntuird hy Scct ion l?(x) of rhc bbor Codc. aor Ihc p.rrofrm. ol
<br />caniur ud r\,licy numh(rmfre.-1C
<br />a22?€2/a2
<br />-t
<br />ccdilirhd in rMF.LnrFncco, rhc $ork tu $hichlhn pcnnir is i$ucd.l sh lln.r..rrloyr.yltrn inrnynurncr
<br />\, \t, b.coft suhicr k, rh. wolkc^ .o lFn\arnr h*sofclliturnia, md +Ec rhd il! {houil bcconr sulrJccr ro rh.
<br />work. conrrn\rr6. pn,vi\ions orsc.rn,n.1700 ofrhc L uC.dc.Id l.lird[wil[comt]ly wirhihosc poli\n,is
<br />WARNINGT F,iturc r. wur. *orte6' conpcnsarion ovcmSc is unl l. nnd shall ubjccr !n cmnk,ydr fu dirninrlpcniiics rnd
<br />.ivil ilnos ut ro oft hundn{ rhousi.d dollrs (SI0O.o(X)). in .dd n,n, danugcs as pmvidcd lnr ihc
<br />Suctnri 3076 dfrhc Lrk,r Codc. i.rcrcn.nd bary s iccs
<br /><,*
<br />l hcrcby rlltn ondcr penalryofFlury rlur l am li€n$d uid.r tr.vhio. olCh.t c! 9 (.onnxnci.E *ilh SNrion Tfln) ofDivisn,n l
<br />oi rhc Busincs.nd Profe$ions Corlc. ud myliccns is in tull r.rcc and ctrecr
<br />c-.y-4 Ep
<br />caNsIxl]cuoNtENDtNclc.ENlI
<br />I hcrcby itumuM.r pcMlry ol lcrjury rhd lhc.c,s n.on{flcrion lc.din8 o8cncy Lrrhc pc.iormncc orrhc $urk tor whic[ riis pcanit is
<br />i\\ucd rs.c ll)97 Civ C I
<br />ATIUCANfDIiCIAAAIIA!
<br />I lNhy Imundcr pcnrlry ofperrur, onc ofrhc f{nb*ing dcchrarnnN:
<br />D.mniln)n Pcrnrih Asbe(os Norificarion lcdcr0l Rcsullliotrs (lilbrl). Pan6)
<br />-Rcqun
<br />n LclrcroiNoliricari{!,
<br />l..nif.vrhnrrhc l.dcr li(!!lxrions r.!rrdi'rg r\lrno\r.ntrivrl c orqrfl'.nhlc t) rlris jir'ntr
<br />.u/zrdf,hd I hnvc rc.,r ,his arpricariotr !trd Iirnnllion nrnrccr Lgr.d r,cotrDllwirhall CiryrndCounly J
<br />ordinrrccsa Sriic Laws rcl(in8 totui[in8 ri7e..cp'c\cnrrrtrc\.1 rhnCirtrtrd CounrykrcnrcrnF,nrlr
<br />rlrrc n( to cd |'opc t ntr i'trtc(r
<br />>pplunr o.
<br />^renr
<br />sisdrrre
<br />43L
<br />!
<br />*,.,-y'2y'a
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />ftoof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />l\/asonry
<br />Pool Fence
<br />T-Bar
<br />Handic ap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />/z> )
<br />FINAL ?-24,/b ,41,*x
<br />Certif icate of Occu pancy
<br />Notes Remarks , Etc
<br />\
<br />tt
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