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BUILDING. INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrchy rlitm undcr pcflaltyoft rjury rhrl I am eicmp! frer. rhc Co.trrns Li..n\c Law lor lhc followins rcrsn (s..?011.5
<br />B!\inc$ ad Profc$n n CL\]t): Any cily or Coutrry *hi.h rcquiEs r lcrn lo consrrucr. .hs. imprcvc. dcmlnh or rct'on any
<br />ntudm, nrn b irs hsurcc. also rcquircs thc +plic.nt for $€h pcln l k, filc i siENd {dcmnr lhol h.or shc is licentd Puruant
<br />ro rhc pDlisii{s ot rhc Conra.ttr s t-iccnscd kw (Chdfld L Conrnrcncins wirh Seclion ?0@ .f Oivision I of lhc Busincss and
<br />Pfl,fcr\ion\ Codc) or rhrr h. or rhc is cr.mpr rhc.cron and lhc bash lor lh. lllcsed cicmprion Any v,ol.rionofScclhn?0:ll5 $y any
<br />{plicanr ror rl,crnir subj.chrhc irlli.ant lo acivilrnrltyofnor rmrcrhd nle hundoddoues ($stxj).
<br />-1.
<br />as owncr olrh. rmFnr. o. m, cnul{Drc\ wirh srger }\ rh.n v,t.onDrtrsrtiotr. $ill do rlE *o.[ and rhc {mruE is rol
<br />idrcndsl d orcrcd fd sh (Se 7O,l4. 8usincss ond Pnfc$ions Codc l'h. Gn rrcrr's Li.cnsc Lrw docs nor .{'Ply ro rn owic' ol
<br />rhc nn)Fny wlir buiks or inlptuvcs rhcNn. {nd wh. d,Es sch wo* hi.n{cl, or h.rclt or rnnrgh his oi h.r owr cnl,tbyecs,
<br />tiolidcd rhar \uch impo\tmnc d ftI imcndcd or oil]ton for a,L lt hN$ar. rhc l[ildin8 or inrovc'mnr i\$ld sithin,,nc )$r
<br />oiconDblion. rnc Owncr Buikl( will hrvc rhc bu' dcn of Srvirg rhrr lE or shc did nol l,lild or i'r!,n)ve rhc pnDciy for lhc Pu{,o$ of
<br />-l.
<br />r\owncroirfic pmpcnr. sndxclusivcly cont,.rnls sirh li.cnscd.o.rrclonro conslrucr rh: pojccr (S...704,r. ausrcss
<br />Jd }hnissbnG.:ThcContcroast.iccnsctjedocstror0!J,lytoanowncrollmpcnywh()buildsoriDrrrovesrhcrcon.
<br />and qho conracrslorsucnrrojcdswnhsCorta.rorls) liccnyd pr^um LrrhcConrrlois Li.en$ ljw)
<br />I rcrcnU undcrs€rion .B &PC ntrrh$i.rn
<br />Dsl€ , O*ner
<br />tyoRxrR\' at)ntPl'NsATI()N
<br />[eclanauQN
<br />I hcrchy atli nu cr p.ndlyolpdjuryoncofrtf, follosirg dcchrurt,ns
<br />-lMvc!n,l*illnuirrninnCcdiararc.fCotrscnrtuSclllnsuicforwork.N
<br />cory,.n\rrion- K Fovid.dforbrScctionlT0Ooilhc
<br />Labor Codc. lor thc l,cnbnumc ot rhc work for *hth rh. p.nnir iq issucd
<br />I hrvc and will nlrn .in wo*crs comDenrrrion insurancc. us rcquircd h, Sdrrion 1700 ofrhc tjbor Codc.l'ot rhe rrrlnht!tud of
<br />rh. work lor whkh ihis pcnnir is issL\n My sorkcn co'np.nsalio! insrrMcc uri& drl Flicy numbcr oc'
<br />,'.lryNu hcr.
<br />-l
<br />ccnifyrhor in rhc I'crfortuncc olihe uork ro, whi.h rhis pcinn is issucd. I shall nor emrlo, any Fr\.n ir,try manmt
<br />so as t, bc..nrc \!hlc.r $ rhc wolkcis conrpcnuiofl lawr orC{lifonir. ind o[rDc rhd irl should beom. subjr-l lo lle
<br />wo,k€n compcnsarbn proliiionsorsftiio.l?mofrhc Ijbor Codc, t shall.lodhwirh.r,mplt wnh Ihs Pmvtions
<br />WARNINC F.ilurc ro surc workcn'conu,.nscrion corcEgc is unhwrul. d shall subFr on cmpLrer ro.riminrlFuniN !trd
<br />) h onc huturtn ihousnnd d.lla^ (Sl0l).lXX)). i'r ldirnri to rhc co( oi comnrn\rrii,n. da r-!cs ds frovilc(l ltr rh.
<br />sccrnrn 3076 oarhc lilin c.d., inr.r.sr and.trorfty s fes
<br />DECI.AIA.IIQN
<br />I lrdby.flnnu.d.rp.nalry.rrc.jurrrhal I a liccnscd undcr pmlhion olChlprer 9 (co'nmfti.8 wilh Scclhn 7000) orDivkion:l
<br />oi rhc Busincs u.l Profe*ioos Codc. trnd mylic.nsc is in rnll lora und calccr.
<br />Li.c.scclassr-
<br />D e: >-t/ -/8'
<br />{:ONSTRI](:TION I FNDIN(i A(;ENCV
<br />I hceby rflirn undcr FnlhyotpcrJuryrhar rhc6 h r con$dcrhn lcnding.gcncy aor rhc rirfottuicc orrhc "ork for which tht lEmir n
<br />issucn (Sc.. llr97.Civ. C )
<br />APPI (]ANT I)I'CLIRATION
<br />I h.E'by.fiirnr under pcnnhyotp.ri!,y otu orrhc rrnlosrns d..hariuN:
<br />ocnxrfnr Pcnnf$Ash.slos Nolificrrn,n lcdcrll Rcguhrnnrs (Tirlc 40. Pdr,
<br />Rcrtuncd kncr oi Notifi curbn
<br />I.Lnifyrhrrrh. fcdcmlrc3uhrions rc8ordi.S ash.nos rcn,ul arc nor rpplic$lc t) rhistrojccr
<br />_l ccnily(hrr Ihrtu rcrd rltir rpnli.rrn'n md nrrcih r )vc i anndi,)n is.om.r l ngrla t'.o llr ly wilh ill Ciry and Counrt
<br />odinamc\ ud Srrrc ltrw\relarinE r! building h \ (-'rvr (1nn rr..nrcr uF,nrlr
<br />rli,vc n.nrioncn !rop.ny ior inspccri(r
<br />,\ppliunl or ,lAml Silln{lum 7-tr-/8
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsu lation/Energy
<br />Drywall
<br />Brown Coat
<br />It/asonry
<br />Pool Fence
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certil.
<br />FINAL YIL'IR 7-vn.,fl,{A5 /
<br />Certificate of Occu anc
<br />Notes, Remarks, Etc.
<br />SITE.WORK
<br />Ext./lnt. Lath
<br />T-Bar
<br />o"", 7- t/'/8
<br />Lcndr\ Addss:
<br />-
<br />tt
<br />I
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