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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNIiR BUII-DEi DIiLCARATION
<br />I herchy al6rm lodcr lcnahy of pcrjury rh l am cxcmpr hom rhc G, raclos Liccnse Law lor lte follo*ins .ersn ( st 70.l l 5
<br />Businr* and Pi(rfcssion Codc): Any Ciry or Colnr, which rcquiE\ a pcrmir ro con(dcr. allcr, inprov., ilcnDlhh or rcl,ir ,try
<br />nrudurc. prid ra irs i\rur.c,.ln' oqut ! rh. npnlkrnr lnr such p.dir ro filc r siBmd drrcmm rh,r rror sh. is liccnql iusu!tr!
<br />io rhc lDvisbns o{ tlE Conrracrois t,iccnrcd Llw (ChlPlcr 9. Connnencirr {irh Scclion ?mO ol Dilhion I or'hc Bu\lncs and
<br />Pmlcssiotrs Codc)orlhrt hcor \hc hcx.mpr rhcEfro .nd rhchasis fitr rhc,llcgcd cr.mfln Anyviohrnrnofsdi,nT03l56trny
<br />applicr tu a pclmir sutjccls rhc arplicanr lo acivilpcnaltyofnor mrcrhsn fivc hundreddollm (S5U))
<br />-l,
<br />rs owtrrr of lhc rrclfny. (trnrycnlloyccs s h*r8cs* rhcr \olc .onrN.sarion. \rill do rh. work 0nd lh. slnr1urc is trol
<br />i'ncndcd .rolltrcd lirr slc lS!\ 7041. Busirc$ and Pmfcsios Codc: lhc C'oorrrcr.i\ l-iccn$ Llw do$ nor orply t, rn owncr.r
<br />rhc pmpcny sho huilds or i'nprcrcs rhcm[.M who di*\ such *o'k him$llor h.rsc]for rhouBh his o. hcr oqD cmployc.s.
<br />fiovidcd rhrr su.h impmvcmnis m nor inrcnded or o crcd tor $b ll t.!cv.r. rhc 6uildi.g or imnmvcm hsokl*irhir,'ncrr
<br />of.o Dkrion. r,L Osn r lluildcr will hr{ rh. bunLn ol povirg rhd 1.. or shl dil ar buiu or inrprovc rhc In)Fiy rbr ihc IrUrIr){ of
<br />-l-
<br />rsosmr oflhc Dor.ny. incr(hFiv.lycontdin8 wnh li.cnrd .o trt ructors lo con\tBcl llE |micl (Scc. 7044- Bu\ilrs
<br />r.d h)id\bnC.dc: Thc C.nta.toa\ l-i..nsd l-aw{lo.s nor rpplyn, .*n.rofprcp.nyrlr,builds.rintrolcsihcrc.tr.
<br />rnd who conhcls r'or $ch nm]ccls wirh rConhcro(n li..ns.d Dutrurnt rorhcCo racktr s Liccnr ti$)
<br />-l
<br />rncxcmpr undcr Sccr
<br />Dole: Orner:
<br />TVORKER$ C{)ltlPrtrlSAT6N
<br />IEILAAAII]N
<br />I hcrcbtrtlilmr crpc.0lrr.rrf,rjrrloncofrhctllhwir8dccltrlrtnr:
<br />Ihr\rrilwillnui'nrinaCcdifiurcolCon\rtrrk)Scll:1tr\urci(n{or[$rcomp.n\inr,r\t'(trit]cdlnrhySccrnnr:17(l)ofrh.
<br />,itln (i,J.. lar rhc p.rfonnMr ol rlf work ntr ! hich rhc pcflnir is i!\ucd
<br />_l h0ve and will n0intoin workca comp€nsali.n iNurnnc.. ds Ntuncd by s.cr ion l7u) of rl1c tjhor Codc. fo! thc lcdomurcc ol
<br />rhc work t{trwhichthh ncnnit is isu.n My wortcrl $qE.srlion insur!trcc caEicr a polic, numhcr nc
<br />P.licyNunhcr Exfncs
<br />arID_ __,^**F
<br />CAliiIallql()ILLriNDlNCrrQlNlI
<br />I hcrhyalftrun.lcrFrrlrrolpcrjlryrhlrihcn is!coosrrucrbn lc in8rscrcy,nrrhcp$tu.rx.corrhcworkr.r*hEhrhi|tnniris
<br />i\suc (Scc lll)7.Civ. ( )
<br />AIPUCANIDLCLA8AIITN
<br />I h.Rby trflim und.r rcnrlry ol r.rjury onc ofrh. follosing Jcclrrarion\
<br />l)cnrniion P.flnirs Ashc\ror Norificrrion Fcdcral Rcsuhriotrl (l irlc 41)- l'xn6)
<br />-Rcq!irn
<br />Lcllcr of Norillcllhn
<br />l.cnlrrthri rhclcdcrilrcBuhibns rcBndiDg osh.r.s rcnxivrl ir. NI qrdi.rhlc to lhn pn,rccr
<br />-l
<br />.r'rili rhi I hr{ rci th \ rpJ,licrri,r rtr(l{trrc rl,d rrc.r lrlrN trr ro [v srh r]lcLlyr rr ConDlr_
<br />ortlinxn.s JtrJ srrrc li*\ nhinS b hu prcsc rrivc\ of rhi! Ciry Md ct)xnr! ro c.r.r qrtr tlt
<br />rh.vc nrrri,,rd DoNriy lnr iDstc.ti,rr
<br />,{pplicrnl or Alcrl Si|lnsl
<br />Prmilce nnmelprinl)l
<br />,.4 ",6',/(/(
<br />lhc str,vu inn{ruri,,n i\r
<br />".""/"*t'r*,r"*"^
<br />U/^'
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation ,1
<br />Rool Sheathing f/is/t{--,44L7
<br />Shear Wall ' "L/
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ir/laso n ry
<br />T-Bar
<br />Handi cap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil.
<br />FINAL i Itult9 I 'tvytgt* /.'e-,\
<br />Certilicate of Occu tpancy
<br />Notes Remarks, Etc
<br />Pool Fence
<br />-l.cnitrihar
<br />inrne per{orruhce.trhc sork tor whichlhhFlnrir k issucd- I shall nor enlrhyanyF6oi in,nyn',nn&
<br />$ s k, b..orm subFd ro rhc wo*crs conlcn{ n,n hwr of Califdnir, o 4Ed rhar ifI should bcconr subjet ioth.
<br />qor*.N' ompcnsri io6 psvisiotu of SRrsn l7(E ol rhr lnthr C.dc. I \hrll. fod hwirh (rnply qirh rho$ F,visions.
<br />WARNINGT riilurc to scurc workcn' comFns.l ion .olcruBc n unlaalnl. aDd shall subjccl m cmpbycr lo siDind rDEllks a
<br />civil fines u! Io onc nundrcd thous.nd dolles (Slo0.uD). ir r,llrJon ro_rhc ."n nr cJmFn"rtion. donE8c\ o\ rrovilcd for rhc
<br />sc\rl,n.\,76 ofrhc L.t$ ( odc. inrcrc{ and arorrcy', rcc' 1 ./ ,/
<br />,,,",8ll Yll .Y n"ri*n,r/ {//C 0e-- r-' rllrsru conrnt ron
<br />DICI,ATAI,IgN
<br />I hcEby nlfirmundcr r.n0llyofpcrjury rhal I am liccn*{ undcr pmvtmi ofCnaprcr 9 (.ommmitr8 with Ssr6n ?OO0) ofDilision 3
<br />of rhc ausin.lsand Pbf.\siorN Code. drl ny liccn* i\ in fullftncc MJ cftecr
<br />rfrvfrr
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