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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDEi Df, LCARATION
<br />I hc,cby !finn undcr pcnalry ol pcrjury rhat l0Dexcmtr iroD rhc C.nlrndor Liccn\c Liw lor lhe t lo{inB r*s lsc.70ll5
<br />Busnrss lnd Pnrcs\ion Cdl.): Aiy Ciry .r Colmy *hich rcqutcs r pcr.rir b .on\ifl.r, ,hcr. nnprovc. d.n hh or rcNt any
<br />stncrurr, rrior ro irs tsunn.c, illo rcquircs rhc amlicanr for su.h !.m ro nh, siSmd sldc.rtr' rhar tEor shc ir liccnsd puruanl
<br />ro rhc pmvtion\ ofrhc Conriacrq\ I-iccnscd liu (Chlrrcr 9. Gmmncin8 wirh Secrion 70(x) ot Di!isn,.I or rh. Bnsincs and
<br />PofcssnrnsO)d.lorrhlrh.orshci\cr.mprrhcicfiofrrndrhchNisf.rrlr.nllctcd.rcmnriob. Anyvi.ldio oiSccrio70.11.5byany
<br />applicld lor ! pennil subjslsrhc applica ro acililpctr!llyolnor mErhrn fivc hundrcd dolh6lS5@)
<br />-1.
<br />0s owncr oi rhc I'lopcn], or my cnrlloyrrs sirh wigcs ,c rhcn sh conlpctrs.rion. Bill do lhc *ork ud rhc slMr!rc n Nr
<br />irrcdcd or .,Icrcd for slc I SN 7044. Busircss atrd Pmfcsions Codc: , hc Conhcroi s Licensc ljr does lol apply t, an osn r or
<br />rh.ln,Fny who bdildror inlmrs rhcNnr md wh. dms such w)rk him\clfor hc^claor rhii,teh hi\ oi hcr own cmployccs.
<br />pmvilcdrhar \u.h nrtrornuls m mr iorcnlftloroficrn f.rah ll hos$r. rhc ti{ildi',8 or iryove'Ed is sold virhi', one Frofconlhlion.llt Owncr auitlcr sill hrvc ltr bur&. orrovirr8 rhlr hc or sh. did mr buik] or inurow rhc pFpcny lor rh. prF)r or
<br />l.r\o*nftofrh.!tuprdy.anruxclu\iv.ly.ontarrir8wirhliccn\cdco tr(,E ro .on{rucr rh( l()j.cr (Scc 7t}1-{. Buinc{\
<br />nl hnb$i Codc lhcConiruclo.\ l.ic.trse Ltrsdocs n.r apDlyto anorncr ol,rn,pcnt*ho huild!.r nhtrolcs rh.rcon.
<br />rtrd who.otrhfdsu.hpn&chwirh0Grnrra.ro(r)lk{i{dpursunnrr.lhuaontr.htriLi.cnsctjw).
<br />I anrdcnlr udcr Sccrion_
<br />LOAtrEIIS:IOMTDNIAIION
<br />I)ESrISAIIQ!
<br />I hercby ulfi rn under lcnahrof ne.julyom of rhc lollowin8 d(llrlrirns:
<br />-lhlvcani$illnuinramaCcnikarcolConscnlloScll'l,rurelor*orkcr'compcnsarn,n-!\
<br />pmvidcdturbys ri,,nl?0oofrh.
<br />Llbor Co<lc. lor thc I)erformmc of rhc work l'or $hich I hc ncnDit is i$ucd.
<br />Ihnlca w ill nri sin solkdr! conrlr $rnD nr\Dramc. 3\ rcqu n d h) s&1i :l7lx)oIrh.LtkrCodc.Inrrhepcrfonmnccoi
<br />rtu rr forwhkh rhis pc'nir is i\$L{ Myq.rkcE co'npcnssri.n in\ufl .c oEicr ndFli.ydunrhcr rc:
<br />I(nifyrh,rinihc pcrfo.mrcc of rhc work f(tr whi.h rhi\ pcrrnir i\ i\sucd.I shrll or cmpl.y flry pcson in any nunrcr
<br />$ $ ro b.onf, subj$r io rhc qorkcn .onD.nsrnon l.ss or c,lifonria. lnd |8rcc thrl ii I should tlc$nt \thjcd ro rlf,
<br />*orkcn compcn$rion pruvkiotrs oiScclion l7tlo ol rhc Lnhr C.rlc.l stull. lonhsirh.onuly wirh rtor pn,vi\n)ns
<br />WARNIN(; l:n'luru n, {c!r uorkr'\ coitpc \dn)n .o!.rxgc ,s u lJ\lu cnrtloyer lo riirinll l.nalris m!
<br />n,n. d.mi8cs as ,'rovAcd n, lhc.,ril ft,.\ trI i) otrc ltundrcd rhou$iJ dollr^ l$lll).lx ).i,,rddri(inr
<br />sc.rnnr:10?6otrh. trbr codc, inrcici rtrd&orml s Itc\
<br />I hcrhrrinnruMcrFn,hrolFrjuryrhd I m lidcnsd cr9(nNrcncingsirhS.crion7UX)rof Divi\n .l
<br />t(rr)
<br />I h.nht nmrm undc. Ful'y 6a pc.jury rhd rhdc ir ! con(rucrbo hndi.s .g.my ror rh. p6rolmn.. of Ih! Ro* for which rhh Isnil is
<br />hsued {S(. 1097, Civ. C,).
<br />A.TIIIIANIDICLAB&IIO!
<br />I tErb!nfli nuDdcr |xtrtrhy ofpcqury orc ofrhc lollowrtrE rlcclnrdtns
<br />Ocnk,lin,n P.rnirs A\h.{us Norifi. i()n Ftd.fll R.AUhr i()n1 ( l nlc 40, Pnd6)
<br />Rcqrrc l-orrcrolNorii.drh
<br />Set Backs
<br />Erection Pads
<br />Subf loor/Venl/lnsulation
<br />Rool Sheathin s t V>)t*7nzanil-/t1
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />l\,4asonry
<br />Pool Fence
<br />T-Bar
<br />Handic ap Req
<br />De puty Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL #>n/tt EnrD/h /tn
<br />Cerlil icate ot Occupancy f
<br />Notes, Remarks, Etc
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />of (hc Busnc$and Pmf.ss.nsCodc, rnl nry liccisc h h liill f(re akl cl Lcr.
<br />t ndcr'{ AddrcN
<br />-
<br />-l
<br />ccniiyltd rhc ltderDl rcsuhrn,is Eruditre osbcsios rcmvll !.c nor,prli.dhlc x, rhh ptuj.tr.
<br />Lcn'lirl'ln,v.r.dtlrhrJotlrcor(.r,rde.r.rh+'hcoh+.rtrl.rturntrl\nr(t.IrF,erocnnrbtrlhtrllCyund.unr)
<br />.d,nrn!c.ond sL c L1*srhriu ro hurldiu ! nn{rucf n, or hcrch\ auth.rfrcnc{nhrnc. n,lhhCir! rftlCrunr} !'.nrfl un nrh. /
<br />ftotr,rnrmmd rtuFn) nr m.plrron prp.csy' -f . t /
<br />l:.*:'.'"'-"-;"]:*" Ury* D'r' ?/1:1/
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