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BUILDING. INSPECTOB RECORD
<br />SITE.WOBK DATE ID/SIG.COMMENTS OTVNER BUILDEN I'ET,CARATION
<br />I hcrcby rfinnr undcr Nnrlly of p.rjury rh l !m ei€mfl ftrm rhc Ci,ntn.tna LEcnsc tis {or lhc f{,lk'wn,g r.r\on (sc..7orr 5
<br />Bnsiocsr ad Prci.sln,n cdl.)r Atry Ciry or Coutrr, whi.h rcqtriEs 0 F.nrir ti ..n{dcr. rlrcr. nnflovc. d.nnlish nr r.nrt trny
<br />iru.rurc. prktrr. ns issuancc. aho rcqutes Ihc arplica rbr such p.nnirk) filc r silrcd srarcnEnr lh0t hcor shc i\ lki:.d Nrsurni
<br />lo rhc prorhn,i\ otth. Conrrciofs Li.cnscd tjw (Chryrd'J. Comnrcncir8 sirh Sccrion ?fiXl of Division :l ol lic Busincss nnd
<br />Pft,fcsn,n\C.dc)orrhdlforslEkcrcmprrhclclrommdrhch.sislorrh.rllcgcdcrcmPrion. nyviohrin{lSarnJn70rI5h}rny
<br />.I'lrlic0Dt forrpcmit sub].cls rhe arplicant ro acililpcnrhyurnor m.rcrh,n livc hutrdreddoll6 (551())
<br />rrcnKEali:rautINsarlI]!
<br />DES,IAA.IJA!
<br />I h.'ct'y rfiflnxnd& FnalryorFrjuryonc ollhc lollosinB dNhrario.s:
<br />-l
<br />hlvc rn will minrain a Ccnificric of co.\cnr ro scll lnsnrc tur q ortcK compcnsarn,n. a\ F,vilud Lt by S(l ion .lTlI) ol rhc
<br />bhor Codc. lor rh. pcrfomune oflne wort for which lhe pcmr nisnd
<br />_l harcandsill mxinrain sorkerJ .o nD.ns r! nJn rn$hmc. rs rcqur.d l,y S(lion -l70O.rrh. ljhot C.dc,lor lhc pcrtorun.e of
<br />rhc *or[ n shi.h rhis r.mii i! issucd. Mywolkss ompcnmtiotr insur c. crrier ar Fli.ynumh.rrc:
<br />,,{/0tL6.4! tl-t2
<br />SCurcf ?) 3?l 'i
<br />-l
<br />ccnify rhal in rhc pcrfo.mlEc ofrh. work fu *hi.h rhis r.rnir is ksucd. I shall nol cmpb, aiy p.N'n in any ntunncr
<br />v, tr\ b brL\,tu subj.cl r. th. workcr' con!.ns0l ion laws of Californir and acEcrhrr irl should tEconx nrh,ccr lo lhc
<br />woa.r cDn1ncneiiontmvhio.s olSNrion 37mof rh. Lltnr Codc.l \hnll. fonhwirh comnly wirh rho{ rmvhi{ini
<br />WARNIN(;: Fiiltrrc k, ecm sorkm conDcns.tion corrosc is unla*fuL snd lhJl subitr drybycr kr qiminll Fnrllics and
<br />.ivil 6i.r ut ro otrc hundrcd lhousand dollan (Slu).(XX)). in addirion ro rhe.oe ol .o,nnctrs0lion, d0nE[cs,s [ovid.d ld rhc
<br />\n rtr,n.li'7r.,llh.lrtn codc. rnrcrc{ md dr.irE} ' l.c. -,-
<br />o,,,. . Attb 7z.rtfi-",* >(tu-L)@cLlliENsel.llBrralna
<br />DICI.ABAIIQN
<br />I hcrcby alfirn utrdci Fnalryofpcrjury rh,r I am liccnKl lndcr pmvisnr.rCh.flq 9(.o.nmncins *irh sc.rFi ?000) oI Divhion:l
<br />or rhc ausincs Md Prcfe$ions Codc. ai my liccns h in lull fi)N a cffc.r
<br />t>IA ZDf*5
<br />CONSTRTJCTION ! TNNIN(i A(:IiNCY
<br />I h.Eby ltfirn undcr ranilr, or p.tuiy rhar rhcrc is, c.nslfldion lcrdin8 ngcD.y t{tr rhc rcnnniu.cc olrhc sork Lr whlch r8s Il(nnir is
<br />isucd (Scc 1097. Clv C ).
<br />Set Backs
<br />Forms/Sleel/Holdowns
<br />Ereclion Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq
<br />Framinq El)r l@ l/(frr)
<br />lnsulation/Energy
<br />DtyWall
<br />(fxt.4^trt. t-atn 8,h, IrY ,.\r14 )
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certil.
<br />F|NAL (d{ )7/ty/B St..*t
<br />Certif icaI6 ol Occupancy
<br />-Dl€{es, Remarks, Elc.
<br />I q
<br />f o ,9t
<br />U
<br />-?
<br />Shear Wall
<br />l. n\ own& or rh. I,rolxdy. d my erylores wirh w{scs as thcn sb conD.nsdion. $ill do lh. wmk und the slBr@ is ior
<br />inrcnd.{ or ofrcrcd i'or sL (S€ 7044. Bx*i.c\r and Ptufcssi(,n. Cod.: Thc Conrradois Liccnse l,e do.r nor dlpl, to an owrcrol
<br />rhc pmFny wiobuildsori pmlcs thcr@n. {d wh. do6 sucn rod. tnnsclfor h.*.lfor Ihrough his or her own cnDhy(}.
<br />prorid€d rhsr such iopDEmnrsm m! inrcndcd oroitarcd r.r sh Il ho*crcr. rhe tdiHinE or i.Dmvcmnl h $h *irhin onc }!U
<br />ofcon{,hrbn. lh. owmr Buii:lcr will haw lhc burdm ol pruvins thal hc or sh. did mr hdild or iE{row th€ I'mFny ldr tlt ru{r,s .f
<br />-1.
<br />$ ow.cr ofthc ropcny. rmcxcloiiv.lycontdcrinS *irh li..n*d co.r$hn ro on\rtu r rhc proJ.tr (sc..7044, Bu\ircs
<br />.d P$f6sir Codr Thc Conrr&tol s l-iceo* Low docs mr aFpl, to an oM.r of nmtE y who huilds or ihP v.s rhcrco..
<br />and sho o.rracrs for.u.h pbje6 wirna Conhcro(s r li.nscn ,)unuanr b rhcConracr.fc Liccnsc bw).
<br />-l
<br />am eiemfl ud$ S€di.n-. B & P.C. lor this rc0sot
<br />Dore Oun.r
<br />n,".. PC / Zot?^...",*","y=
<br />ATIIICANT.DECLAMII$i
<br />I tf,nhy lltr undcr Fnlhy.rpcrjuryonc ofthc followine dccloralions:
<br />t rE,lriruPcirn(..A'hc{n'Norificrr.nn fc'lc'Jl RcsulJrl F'1 1.1u. P01o,
<br />ff"*n"o *,,", n,
<br />"n,,roo''on
<br />f*niry,r'"r,r," r"au.gulalions rcsnlins {sbcsros rcnrotal ard nor l|tflic$lcro rhisrroic.r
<br />2#-.,'ry 'r,, rr,,r".,0 'r,i\Jrnlil r,n rBl {Jre rhd rh. abvc n,ro.n iotr k comd Lsd k, ..trDlr wirh all ciry end counr,
<br />;rohJftc'rndStirctrn:rcLtre,!huirdi's,i rrdc'n.1 :rJhr'.byJUr}^r,crcflc.cnrJri\c\ rrhF.
<br />'Jni]C,'Lnryx
<br />cnrc' ul\rrh
<br />\n.crionnumo{\ , I
<br />nro,,,,,",n"*''**,,*f 6Jo*r.4u Dut" t ""1 Zl"t
<br />""-,',**",",,^",,X "ad{/.. tr J
<br />t(
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