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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE IDiSIG.OWNER IiUILDER DELCARATIoN
<br />I hcrchy afllirn undr p.nllry {)r r.4ury rhar I m dxrmpt fn'r rh. Conrrofi Li.cnsc ljw aor !h. folldvin8 rcis,n l5cc.r0.1l.5
<br />Ausircs trnJ Pdisio codc) An, Cily or Coutrly whi.h nquncs . Firnir to ..Nlrucl. rllcr. improvc. dcmoli\h or rqrn !n,
<br />{fl.rurc, priqb irs ksurn.c. rl\. rcqutcs rhc anrlicn lor such pcn,ir r. fiicasisned srnrcrmnr rh]r h.or {h. is liccnscd fursuMr
<br />t,lhc rovilions ot rhc Cotrlractofs t-iccnscd bw (Chrpicr 9. Co.nnc.cirS wilh Scclion Tu)O ol Divnh .1 ofrhc BD\nr\l ud
<br />ProfcssionsCodc)orlhar hcorshc hexcmpr lhcrcfromrndrhc b0sis for lhc allcscdcicmflion. Ant!iohrn,nofs..rir,n70ll.5bynny
<br />pplicrnrfuarcnnilsuhjcclsrh.rpplicanrroaci!ilpcnulryofmlnDrcrhanlivchundrcddolld\(35(D)
<br />-l-
<br />a! o$ncr or rhc pmpcny. or my cnlnlotccs wirh wa!.\ n\ rhcn \nc conu(osari().. \rill no rh work lRl rhc n turm i\ frn
<br />n c cd or.ffcic nJr\rlclsdc.T(!4.Businc*rddhofcs\n,n\C.Jc'lhcCoihr.t \ t-i.ctrrc tiw do.s tror rptly ro row,icr.l
<br />rhcpn)pcnv wrnhil.lso! iq,nrfr rhcmn. ori *ho des such wn* himscli.r hcr*llorrhrcush hn or hcr o*n .mpk,y.r\,
<br />pn,vnhd rhirsu.h i,n|novcnrnsrrc turinr.dcil f orlcr.{ ff sak ll lb$dcr. rlr huiun[ or nryrck r rns qirhnorc]ur
<br />ofc.nflcrinr.rh. O{n( Brildcr$illhne rhc t{ !n oa pmvi4 lhd hc or s,E ilil nor huiH or nnpnnr th. rn,Fly f.r r}r Ntx)r of
<br />I.r\.!ncrofr,f,p'o|c(y.i.r.x.hsirclyroittrdi.gairhliccsr.otr!r.rrsr..otrnnrclih!'tmJccl(Scc.7(l1,r.Du{rc\\
<br />Md Pl.llssk n Codc lhc Conrractn s l-i.c.r l,rwd.cs.or ippllro !nornc!olp()pc ysho buildso! nnprcrc\ rhcmon.
<br />trnd who otrrrB Lr su.h ,trr+.ts tr irh . C{n rrki \) li.cfscd pursurd h rhc Gr rnckn s Liccn\c ti$ )
<br />I rn.xcnrpr uDd.r Sc.liotr . B. & P C. L)r thi\ rcrnrr
<br />Dole: O*Dr.
<br />\T( iRKFIiS' ( i IMPFNSA'I I(IN
<br />DIC.LANAruA
<br />I hcrciy iffi irnundcr pcn.hyof pcrjuryorcof rhc rillowi.! dcclmrmns:
<br />-l
<br />hove ard will roinhin a Ccnificarc ol ConEnr ro Sclf.lnsurc io. workcrs con{Ensrrion, as ltrolidcd forbys..rion 1700orrhc
<br />L.bor c-odc. lU th. Nrlbnu.cc oI thc work ior which thc pcrnrir is hsucd
<br />'{lhsvc an'l rrllnBin,oD cnrkcr'comncnssr'nn insunnce. os rcqlnedbySccrion:r?00ofrhcljborCod..forrrr,ldrotrMn.ot
<br />c"-i- 5+ o3
<br />*orkcr! c..,I.nsrri,x, i'rurri.c cxricr x d B,liry trunftcr dclns F=r,.4Qo,
<br />9o O (oC -l8 urr"".c{ -l -t t
<br />l..nifr rhrr ir rhc pfformrtuc ()frhc sork nx whirh rhk p.i, ir is nsucd. I \hrll nor c pby flry t'crsotr in 0ny Dnnncr
<br />v, $hticdinE \uhFllb rhc *n rk ss, conrpco\rl ion lawr ofcrlirbnir. rtrd.sr.c lhxril l \hould hctuf, {hid (, rhc
<br />*orktis..nlncnsari(,npn,vi\n,dsorS.crioi.lT(xlolrhrltrtxrC{xlc.lshrll,ktrrh$irIcoidrsirhrhoscln'vhions
<br />\VARNING F.ilurc ro surc rorkcs'conrfnslridr.ovcrilc is unl.stul. ard shrll suhjccl !n cnrploycr ro simiml linrlrics rnd
<br />civil liDcs u! l. utr. hundrcd thousand dollffs (Slu)). i'r Mdiiiotr to rhc con ofcornpcN.rio., dlma8cs os pmvidcd ror rhc
<br />8-13^r-t_
<br /><.lrf(I.\lt\ll()\
<br />I hercby !ftn udc, rcnalrr .i pcrjury rhlr l0m liccnsdutrd$ nro\ninnrl'Chrnrcrqic,,m'rcn.'ns tr hs\.-rDrTrr0lrr.rDNi\n l
<br />',r lht Bu{nc* d Pmlc,{nnsCodc. dd rylicctr\c I n lullldrcc ind crlc(r
<br />a_b{Do-3 (oq j).3. a--t 3 -tt c*,eo -\-Lo-r-
<br />coxsltlJcuaN-LENlllNc-acEltt
<br />IhDrcbyiftlrrundupcnahyorp.rjuryrhdrh$.hd.on{ crinrh.ding4.tr.!rorrh.pcbnn0nccoflhcworkforwhichrht[lcnnin
<br />i\\ued (sec 3097. Civ. C )
<br />IIIIII]ANIIECLIf,AII9I!
<br />I larhy afltm o&lcr pcnllryorperjlry onc dirhe tullo*i',s dcclMrnn,s:
<br />l)cnxnirn,n Pcnnils Asbc(os Noriticarlon l-cncral Rc3uldions (Tirlc.l0. P.fia)
<br />R.q nc lrrr.rof Norifiuri,,
<br />-l.cniiylnur
<br />rhc fcdcralrcsulalions rcsgding lsbcsos rcnnvll!,c nor lrplic$le ro rhil llnrlc.r
<br />-l..nifyrhar
<br />I I'N rcudrhnaprlicori,,nud rrarcrhnr rhcrhvc ini(m i,ini\cotr cr lasr.{n,con'tlysrhrllCnya.dcoutrry
<br />ortllnrDcc\ rfrl srrl. tj$s rcLri,rg r)ildinE .onsrdcrion. and h.lchy alrhorize rcpm\cnrdnrs Drlhis Ciry and Coxnry t,.nio u,x,n rht
<br />ihN nrtrli0rd pfl,rdy ror
<br />,\Dpli(rnlor,\E.nlSknnlum .-!---l-*^-unrc b t3 "/\
<br />I Q cr v.. \ ""-q ,.,^,) ' tSo"..,
<br />Set Backs 1
<br />Forms/Steel/Holdowns trly'/c?a,--T4Z './
<br />Erection Pads I'I ()J
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulationi Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handica p Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />/ -t'olv!//*f,vuaz 7 /0>
<br />Certificate of Occu pancy
<br />Notes Remarks Etc
<br />COMMENTS
<br />uJ.-\-t--o--
<br />\r-^'-";**-o
<br />UFER Ground
<br />FINAL
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