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BUILDING- INSPECTOR RECOHD
<br />SITE.WORK DATE ID/SIG.COMMENTS
<br />l. us oqncr of rhc F,p.ny, or trry cmtloFrs *irh sre.s al rhcir slc .omFtrsition. Bill do ltE *o,k lnd Oc sldrrc ( frn
<br />inrcndcd oro{crcd lor elc (Scc 7(}4,4. Ausinc$,nd Pmfcsions Code:'lhc ConrBcrois Liccn\c Law docs nor +ply to otr osrcroi
<br />rh. rn,Fny whohil&o' in06rcs rhcR)n. dxl who d{B flch $brt hin$lf or hcr*lf or rhronEh hk or h$ o*n cnr|loyccs.
<br />piovid.d th.r such nqrovcnrnh e mr i.rcMcd or ollcd for sh Il lm*crtl thc trildin8 .r iryrorcmd i\ $kl tr irhin on.
<br />'uur.otrDLiri.n, rtE Ownq BriLlcr will hovc rhc burdcn oi pn,riu thll h. or \hc dd nor huiH or impbvr rhc poFny lor lhc pu4n{ oi
<br />l. rs oqn& of rhc l)()lrr ry. , r cxclu(ivcly dom a.tjr)g snh li.ctrs.d .onticrorl ro otr{rucr thc proFr ( Scc 7(}l3 Btr\in .\
<br />rd h.ltsion Co{lc:]'hc Contacrors l-iccnsc tiw docs norrpplyro trno\rncr orti(,pc y$h. builds.r inuovcs rhcrcon.
<br />rtrd wh .onrdstur $rhttrojcdsanhr Cbnr&ror (9 li.cr*d Nnuanlo rhc Conrrrroi s Li.cnsc liw)
<br />l. n.klr'ln utrtlcr Su!r L{r
<br />D.le: O*ncr
<br />ltoRKltRY CONIPF^ISAT(N
<br />IESAAAIION
<br />I hcrcby rin.nundcr pcoally ofrsjury onc orrhc rinh*iDs dcchrarions
<br />-l
<br />hrvc dd w ill fluintuin a Ccdiftotc of Conscnr to Sclfl Nurc rbr *orksi compcn\ar ion. r\ p vidcd rir bySsion 1700ofrlr
<br />Ldbor c'odc. lor thc ,sfonun.c ol lhc w.rk ld q[i.h thc dmn is issucd
<br />lh!!.rnd*illtrrinrrinsorkcr\'.oll$rari{n,in\rtum.-r\rrquncdhyS.dnrn:l7l]().frhclihorC.dc.forrhcpcriorunc.ol
<br />rh. *oik for whi.h rhis punir is issudl. Myworkc .un{risd idr insurM.o cMicr jrricynunrhcr uc:
<br />.",*, ' Q1fv.a- 9 ) \N JUl.*- c,<- 60
<br />?avsC- ar..{c t t - \/.lzoia-- --t--- '
<br />-lccnilyrh.riIrhc
<br />Nrio nrn.c ofrhc work lor w[ich rhis pcnnir is tsucd.I shlllno! cnpl{)y]ny pcso. in rny ntmncr
<br />w b bccom \!bJ<r r.rhr sork.rs mmFn\aiioi h*s ol Calilornia. rnd lgtocrh irl \Muld h..onr nrhlc.rrolhc
<br />work.r\ co'npcnsrrn,n pmlisnr.\.fSccrn,n:lT0Oofrhc tjhr Axlc.l shrll. r(Jnhqh..nrjny sirh rlFr pnrvnios
<br />WARNINC: rrituN lo $curc workcrs oqrcnsatbn ..vcn8c is trnlflwtul. \h,ll \ubr.cr !n cnrloy$ k, $i.riMl Nnrlrt\ ind
<br />civil lnB up I. otrc hundrcd lhou{Dd dolllr ($roo.llxrr, irr lndilion ni ih. con.l.onrFnr rioi. dltr$g$ trs proriid ro. ihc
<br />::."feA'?IA "'-'l
<br />DEC'JAAI&N
<br />I hcBby,ftlrn undcr Fnrxy oi pcrjury lhlr I !n liccnsd trndcr pmvnion olCha/s 9lconmncins wirh S€crion 70oo) orDivision l
<br />of rhc Burik\r and Prcrcrsionr Codc, ,nd 6y licenr ir in rull loft drl cfla.r.
<br />Sloq noIBLL-)3 4
<br />! hcrcby n tm uMcr l*n.lly oi Frjury lhol lhcrc h . c.n\rruclion bn<lins rscncy to. rhc Frrotu... or rhc Ror* ror which thh F.nil is
<br />i\\ud tsr. :r(,97. civ c )
<br />AITLICANLDECLAAAIIO!
<br />I hn*,y armn und.r r.naxt or pcrjury utrc of rhc |oll()win8 dNldationr
<br />Dcd,lnionP.trnirs A\b.{osNorili.artrnF.d$rl R.Etrlariohl-lirl..l0. Prn6)
<br />RcqutcdIr drof N.tifi.arioi
<br />-lccnifyrha
<br />h.lcd.rolrqulllionsreEardin8astEsr.srcmvrl!.cnor"rrllcablctrr'i\pmj.cl.
<br />BB *nri ,r,, r r,"* *,a ,r'r q,pli(d i,,n and nrrc rhur rhc o&Nc inro,.rari(,n i\ .orsr I rsd b .o.Dly wnh lll ciry rnl coutrry
<br />.rdrninccsdndShrcLrtr!rclaringrnhuildingcnn{rucrnn.ordhcrchylurhoriz.rct c*nrarivc\ofrhhCirya Counly r,r .nrcr uE,n ric
<br />ri)
<br />n"*n**.*,on*,,K 3 r i^J s*.es.e. 3.lrr-
<br />e/rz(r?
<br />Forms/Steel/Holdowns
<br />Erectron Pads
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Bool Sheathin s
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/asonry
<br />Pool Fence
<br />T-Bar
<br />Handic ap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil
<br />,4,
<br />FINAL g-Lt -ly h,tutd
<br />Certiticate ol Occu (_/pancy
<br />Notes Remarks, Etc
<br />-/lt\.P Q.,t
<br />tt DU (w v*t
<br />4 t*t {}vgt pg-,l,v
<br />-
<br />Set Backs
<br />UFER Ground
<br />v.
<br />OWNER BU!!,DER I}EI,CARATION
<br />I hci.by trfi]fln uMcr pcmlry.f pcrjury rh r I dn crrnU fturn ihc O)nt ror'l-iccnsc ljw lq rhe lblk,*in8 rcrv,n (S.c70115
<br />Busincs rnd Pxncr\ion Codc), Any Ciry or Cotrnry which rcqtrne\ r r.rnrir b .on{flcl. !ll.r. imtmvc. .rcD.lirh "r rurrJt .tr'y
<br />nd.urc. nrirr k, irs irsu.rkr, also rcquncs rhc.mli:nr fd su.h pcnn{ h ilc r siSncd stdcmlll rnlr tuor snc i\ licci\c.l f!^!rir
<br />rorhcp.ovhionsolrhcG,rrrtrcroisLiccn\cdLlr(CMrrcrq.Comrncin8snhS.crionTltxr.lDrrh,on:].frhcBusincs\and.
<br />linrlcs\i{nN G)dc) .r rhrr hc or shc i\.rcnrrr rhcrcrnnn ud rhc hrsis ror rhc trllc!.d cxctrrpri. l Anyvi.l.rionoiSc.rion 70:ll5 hyany
<br />.I)tli.anr r{trrlcnnir srhjsr\rhc mli.nnr k, a.ivil,rtuk!ornur ntrc rhrtr livc huDdrcd dollffi 15500).
<br />5.
<br />(j .-"*".! {
<br />.hnc nf,nrioncd por.n, for r.sln-lion
<br />Appli.sr or A*erl sistrdurcX
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