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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS
<br />?-.-
<br />OWNER BUII,DEN DELCARATIoN
<br />I hcr.hy.afft'n unds rnlhy oi pcrj!ry rhd I d cxcn/ rronr rh. ConrdbN Liccnsc L.w l'or lhc aolk'winr rcasn (sc.70-11 5
<br />Busi.css . Pmic$ion Codc)r any Cily or Counly which lcquiBs . F.rnnl to con(flct. rllci imlnr.. .,.nrlnh ur r!.n rtry
<br />srucrurc. pri(trh its tsu cc, aho mquncsrtu aiplic.nl for such pcmil x, il. a sigNd etrc.Enl rhal h.or\hc i\ li.cnscd pursuanl
<br />ro rhc DmvhioN oI ltE Contracloas Licucd tr* (Chrrrrcr 9. O,frnf,n.nrg with Sc.rion llxn of Dili\ion :1 .f lhc Lusincs and
<br />Pmtus\i.nr Codc) or rhrr h.orshu iscrcnDr thcicfromMd th. b.sis for rlrc allc8cd crcmpl bo Any !i(,lori6notS.criotr?0.11.5 byony
<br />aptli.rnr rorrpcnnn suhjd( rhc appli.rtrr ro tr.ivilp.nrhyurnoi morcrh fivc hnndlcd dollm ( Ss(xrr.
<br />-!.
<br />ff owncr ol lhc pmIEnr. or ny cmployccs trirh tr !3c\ as rhcir slc co rFn\ar i{tr1. will do thc qolk ud thc (rctuE is fr)l
<br />inrcndsl or oalcrci hr salc (Sa 70.14. Bu\incs Md ProfcsnnN Cod., Thr Coikr.ttr \ Liccn* tiw docs trot lpnly ro anowrcr ot
<br />rhc0mFrry who hril(lso. nnpmlcs rh.B).. kt n'ln, {hEs skh f,ort hrnscll or hcr{lf or rhnBh hi\ or hcr o*n .ntloycc(,
<br />pravidc rhnr such nnlhrcnE.rs rE r.r i,tdrdel.! lttnrt f.r eL.li lhru u. rh. huil(li.8 .r nnu.rcnEd i\ hE wnhinonc )Er
<br />of.onphrin. rhc Owncr Bduo will hrE dc bufllctr ofnoving rhf lrc or sh. did tror huild or nnpnrvc ihc pmFty li,r rh puqbs ol
<br />I. ffo$tr.rolrhcrn,pcrry, am.x.hsiv.ly.otrra.rin8 wilh li.cn\cd.otrhcn$ r{, conrtru.r rhc nrcJccr (scc 70.$. Bunrrs\
<br />${ EDns\inr Codc T[c c(,nlutoi s Liccnse Luw docs nor qrnly ro rr o*n.' or lrrol. y who bu ilds o. nnFnrs rlrcrc.n.
<br />atul who .onrarh fin such prcjers wirh. C.trti.t (s)lNnscdfunur rorheC. racloir l-ic.nse liw)
<br />I rncrcDlpr undcr S..li{). B. & PC rhrlhh rca{'n
<br />]IaTruB1.CAUIINI,A.1IAN
<br />DECI,A.BAIIIIII
<br />I h.lcby.ftirnrundcr lcnolry olpcrjury.nc.llhc iollo*ioB dcclmlbns:
<br />-l
<br />hnvc.InwilltrEi oinnC.nificllcofConscnrroSclf-lnsurelor*orlc^ corpcn\dn,n. a\ flovidcd lbr b] SNlnr:l70oorrhe
<br />Lahor cod.. for thc Frfomncc olthc trolt lor which
<br />'hc
<br />p.irnil is i$ncd.
<br />-l
<br />hovcrnd willmninlain workcn compcnslrion insurancc. rs rcquned hl seri{ l7q) .l rhc hho. Codc. ,(tr lhc p.rfonu .c or
<br />rtu wort irtrwhichlhn pcrmii is issuql My*orkc^ co'npcnernn, in\urrmc .ani.r ,rd poiicy nu.rbcr c:
<br />0en\-k --+Nrt
<br />N Nc0 \ 3, s.)93 .-,,,-,,. z[ztl1
<br />I cdify rhar in rhc l..form'n.c ofrhc work for which rhi\ p.rnrir n tsucd. I null nor cnpk'y lny pcron in a., mmncr
<br />n) as lo hcom subjccr to rhc worko s c.mpcnsa, ion laws ol Culilorni( and ,gN rh,r ir I druld lf,com $h]cd ro rhe
<br />workcrl conu.nsltiotr pn,visions olSccri{nr:l7tx)ofrlr litnr (irdc,lshall. fodhwnh.onrrly wnh rh{c !r.vni{,is
<br />WARNINC Failurc ro scuc Norkcm o,npcnsari.n covcragc is nnlitr,nl. inJ \h!ll suhic.r an cnrtloyer t' flifliml Pcmlrt\ rnd
<br />b onc hutrdrcJ rhous.trd ioll$ (:!lllo.(xD) in dilrio \rrnni. drin!.\ {\ jrrnttli inr rhr
<br />u,,".' blzr i
<br />n{dn id.'.{ rn,lx(o'tr.
<br />IB
<br />DFCI ARAT(IN
<br />I hcrcby rmirnunder lrcnnltyofpcdurylial lu lieosd under llorisnnr ol Chaflcr 9 (comrEnci.S airh Sccrion 7(xn) orDivi\ion.r
<br />E rhc Busincssitrd Pmicssions Codc. !frlnry liccn* is i.lullri,ra ul erccr
<br />tt to \zltq
<br />b I zll tt, .-,*.,J< €\i\< (onsi'ruc\ror-' c^! c'l
<br />n \-ufc\c.t\rri /\9
<br />cl)lsrBiJcrlal{rirDlNli-dliElct
<br />I h.rby il6rnund.r |rnrllyolpcrjuryrhllrh.'e i\!coD{n'crhtr L.rli'rgr8ricl ld rhc nc irnrrccoirhc*o ntshichrhi\ Fnnn ^issucd lScc. 3097. Civ. C.)
<br />t ndcr's Nam:-
<br />AIIUSIINLDEIIABAIION
<br />I hcrcby:nim ufrlcr pcnrllyolrE jlry onc otrhe lnlbwins dcclaarn,n\:
<br />ocnD nrn PcrmirrAsbcsros Norificarion ltdcral RcBuHn,ns (lirlc 40, PM6)
<br />Rcquncd Lxn$ oi No'ia(dion
<br />I r.nilrrhrrrhc fudcmlrguldrn \ ngrdnr.r i$.{o\rcNurlrrc D.r lpnlic$j. h rhk pdr.r
<br />.onL\r.Ia8rLrtocomplywilhlllCnyrn counry
<br />rcltrc\.d n.s ol rlri! ciryrrd(iu yri rnr.r trBrrlr
<br />l.cdiftrh llrlc Nld rhi\.lplic
<br />'nlin. trc. rnJ Surc tn\s mlnlinr (,t!u
<br />rh\c 'fttrrtrhcJ rn,n dy r'{ n,n0ario
<br />,tppticonr or,f gmr Sig*rurera
<br />r'".nrir"" *n*rrxinrt, /
<br />Set Backs
<br />Forms/Steel/Holdowns 4 thtlr t t-?k>rd I
<br />Erection Pads I
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Itrlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL 7-/0-/8 .//ela/z @)
<br />Certificate ol Occupancy
<br />Notes, Remarks, Etc I
<br />*L d / 9su'p
<br />tr.nJci{ Addrc$:
<br />-
<br />*,", gl?,1$
<br />Ext./lnt. Lath
<br />Brown Coat
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