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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE IDiSIG.COMMENTS oWN!]lr BUILDER DDLCARA'TION
<br />I hclchy oin.rn u cr p.mlry of pcrjury rhir I an ercnpr imnr rhu Cotrt&t^ l-ir.n{ liw f(rrh.n hwin8 rcr$n(Scc70115
<br />Busi..s\ and Piolcssnnr cl c)r Atry cnt .r C.udy *nich rcquncs n Frnril b co.{flrct. allcr. inryovc- dcnrnhh or Eran any
<br />rtu.rurc. fiitr ro ir\ i\\uam., aho rcquncs rhc amli.atrr fd su.h Fnnir b filc r siSncd stdcm lnal he or shc h lic.n{d p!^!]d
<br />b rhc pmvnions olrhc Conrracroas l-ic.nsed ljw (Chrflq c. Co'nmn.ins wirh sc.rion 7ou).1Drvisnnr 3 ol rhc Busi'rc$ !.d
<br />t'n,fcsons Codc) or rhrr h.orshc tcicnrpr lhcdio .ndthcbnislirth.{lcAcrlcxcmplion Atryvi.l.rionoiSccri T0ll.56ydny
<br />rpplicrnt lor n pcnnit subjsls lhc appli.lnl ro acivilFnihyolnol nn ihrn llv. hr drcd dollrl ($500)
<br />I. ds o*rcr or
<br />'hc Jmlfnr, or my cmployex wilh wr8cs trs Ihci $lc compensar ion. will do rlE *trk {Nr rh. rhlm (
<br />'tutinlcndcd or ofielcd for s.lc ( Sc.?044. Blsincs lnd Prolisions Codc Thc Conkttt s Li..n\. riw d.cs nor lPply h un owrcr of
<br />rhcpmFny $lm hdldr or 4r*cs 1116., n sh, d*s flch *,.1 hinsclf or hcr{lf or ltuN8h his or h.r own cnrlloy.cs.
<br />DDvidcdrh(i such iflIownrnh!cnol irlc cd o! olTcist for lrlr Ii hoecvc( rhc huildi'rg or inpmrmnr i\ snd wirhin onc wr
<br />of.otrDLrir. rtr OwB Bui[hr will h,E thc t{rdctr of pn,vin8 {hl, h. or shc dil mr huikl or impmrc the pmFlly ror rhc pu{x,* or
<br />I. r\ oNmr or dr ropdty. arncrclusivclycotrrr!.tir8 with li.crscdconrodomrocotrnrud Ihe pmjccr (s( 7044. Bu\inrs
<br />and Eoi$siinCndc'lhcConhcroisl-icensel-asdocsnnlamllro!n.sn.rotp(',t y sh1) bxilds or nnPo\cs th.,con.
<br />rnd sh. contmh ftn su.h ltr.irh virh a C.nrd.io(n li.cnscdpusuam torhcControcbfs Liccnsc Law)
<br />I nmcx. rl, u cr S..riotr
<br />Drle: OPne.
<br />woRKrRs' coNIPFNaAT(lii
<br />DECI.II.BAIII}N
<br />I h..ch) rflirmundcr pc.ahy oftcrjuryonc ofihc iollowin8 dcclffarions:
<br />I hrv. rd will mimri. r ccdifi.r(c of C.nscn . sclllisurc tur workc.r qnnp.nsriotr. as pDvid.d forhysc.iion lT0Oolrhc
<br />Li6in Codc.lorrhc Frturmak. of!h. so& Lr*hichrh. p.iinir is issxcd
<br />:lhrvcundwilln inlrin workcn co'tncn\!'n,n nNumrcc. x\ rc+nrd hysd.ri(r 1700orrhc ljhor (bdc- rbrrhc P.rforronceol'
<br />rhc *orl {orwhichlhA pcrmir i\ ismd Mytrork.rs conpcnsrrn,n insrram. caftti kl F,li., nun$s nrc9{urt Contl. L,S- F,.,',,d
<br />c>o
<br />_! ccnifyrnd in rhc IcrfornBmr of ihc worl tu whi.h rlrh p.nnn n issucd. t shollnor cnrtloy any pc.son inanyman.cr
<br />tu dsro b..o r suh.Jccr to lhc wollc( compcnsdion lNs oicrliforniu. and lsrcc rh3r ifl six,uld lrcoft subj.rr lo lh.
<br />wo*cr{ conrFns,riotr [ovisions oiSccrion:]r0Ooflhc tihor ()dc.l shrll. fonhwnhcomply wirh ih.{ ptuvisions
<br />WARNIN(;: Frilur b scur. workctr snlrnernrn .ovc6gc is unh*tu|. lnd shall ru$,ccr ai cmtk,ycr h dnnn,rl ,r rhhr and
<br />.ivil fi cl nt ro oft huMrcd rhous0trd dollns ($l0o.m0). ir ldJirnrn ro thc cod of nnr. dr'tugcs as povidcd li,r rhc::wiG 9.
<br />IIECI.Af,A,IIAN
<br />I hcrcby ofiiflnundcr pcmlryoIrcrjury rhar I !m liccnsd hder povision orCh,rrd 9 (onnrtring wirh sccrion llDo) ofDirkion l
<br />ol rh- Busircss 0nd Pmfcssions Codc, ud my licc.sc is in tull fore ud clfmr
<br />,,..,."a,,.,( '(9 --7
<br />(IE
<br />\17/ (i ,,,*.*}(-
<br />CANSIIIETI'NIENI)INTj.&GINS
<br />I hcEby.fltm undcr Frtrlryol p.rjury ttrr rhcrc t, (on{rucrii,n hndi.g ngctrcy tur rh. rcrlarmNc ol'rhc work llr *hi.h rhis Fmir i\
<br />nrucd (Sc. :1097,Civ C)
<br />AfPLtrANftDr;LtxdullN
<br />I h.rcb, nfiirnr u cr lrnrll, o,r,.rjry onc ofrhc foln,sn,s dcclxrarn,ns
<br />oc,mhrion Pcflnih.AshcstosNoliicalion lqlcrol Rcsulilions ('l ille.10. Pan6)
<br />Rcqut d kncr ofNoril-Elrhn
<br />_l ccnify rbar rhc f.dc.al r.Bnlrtio.\ mgrding dsb. D* rcn)vd dc no( lpdicablc to lhir lmrcl.
<br />4S ..d ily rh'l I tuv. rd rh( lpllkarion alld n0r hd ft. lbovc inrorror ion is corecr. I !E e lo anpry wnh all ! y and counly
<br />ordn n(\rndSrxr.lr{\rulnri S(ihu'l rs.oi!ni.ltri. n l ,Drizc rcrrcscnl0livcs ollhn Cny ud Counry ro.nrft urrtr dr
<br />3h)vc nrnriorcd pop.n, tr itr\t dion
<br />ApDIi. trl or Aa€Dt Si,:nnlore
<br />x-
<br />/g
<br />Formsi Steeli Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Rool Sheathino
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL qhv//9 --(/23 a
<br />Certiricate of Occupancy TT
<br />Notes, Remarks, Etc
<br />-+
<br />Set Backs
<br />Sublioor/Vent/l nsulation
<br />Flood Zone Certif-
<br />kndcr { Addrcs:
<br />-
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