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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COM]vIENTS.OWNER BUILDER DELCARATION
<br />I hcrcbt aflinn uMcr Fn,lry ol pcrjury that I {m.x.nu frod rhc Conir.dom Licc.sc Llw for rh.folr.*in8 reasn (Scc 70315
<br />ausincs md Proltssion Codc): Aiy Cny .r coxnly which rcquncs ! Il mir to con{rucr, ,lrci i'Vrove dcm,lis?h ,tr rcpJn ry
<br />srructurc. lrrhr ro irx i\.umc. ,ho rcquims rhc .pllicont for such ncmir t' fi|. n sigftd sdcorni lhal hc or slt k lianscd lunuMl
<br />b rhc pmvisions ol thc Conrracrois l-icdned ljw (Ch+ler 9. Connncrcing wirh S.crn,n 7U)0 of Divnion .1 of rhc Busincs and
<br />ProlcsionsCodc)orrhdr h.or slr iscxcnrpt lhcrcfrom! lhc husi\ li)rrhc rll.gcd ucnrlrion. Anyriolartnrofsc.rb.T0:ll 5bvan,
<br />ippli.rnr ri, n l,crmil sublccts lhc ryllicatrr io acivillcnrlryoti.r 'retcth.n livc hundrcd dollus ($5oo)
<br />-t{\",.*"",.,,*,,"^-nr.,,,!.nDlorc.sRnhwascsrsrhcirsolcohp.n\arion.willdorh.wod(sxtIh4ndmisnor
<br />inrcnddl oi offcrd ltr $lc (Se.7L!4- Burincss snd Profc*ions Gxlc: Thc Coor0crois t,iccnsc l-aw dxs n.t dmly ro an o*ncrol
<br />rhc pmlcny who hilds or impmles thcE$r and *ho dms su.h *orl himlclfor h.sclfor rhouEh hi\ or hd ow6.mploycc\.
<br />prcvidcd lh such iDprovcmnh trt nor imcdcd d ofacrcd for solc ll hoNcwr rhc b{ildinS or irpm}cmnl h sold wirhin onc ,tnr
<br />oaompkri,n. rh. O*tui auild$ will haE llE hrdco ol povins rhd tr or +c dii mt boild or i'r{evc rhc tmFny ior thc l]utFs ot
<br />-1.
<br />as owrcr or rhe tmldy. an cxcl$ ivc l, ronlrlclins wirh lic.nrd .ont,&,r k' con\|ru.r rtt Pnrirr ( s.. 7014. llu!rc$
<br />rkl Pt,fcsiotr Codc lhcConrrrcnt s Li.cnsc t-rw docs nor rtPlynr aroqncrortmpcdywho bnildsor nnProvcs lhcr.otr.
<br />rnd sho conrrlcrrnrsuchpmr.lswirhaCo raclorl,licchcd plNMr !,
<br />'hc
<br />Contmcloi s l,iccnse tj*)
<br />-l
<br />amcrcmnr qndcr srr
<br />"",.
<br />. aleJ It ""*.,8
<br />I hcr.hy rfinN un,lcr pctrrlryol lcrjry otr. olrhc iollosi',8 dcchrrrn'ns
<br />lhrrc ndwill.rir dirrCcnill.rlcolConrctrrk)Srlflnrurctur$orkc^ .. rpcn\rri.n. n\ Pn,vidcd Ior bySccri$ l7(X).frhd
<br />t-rlv Cdc- nn rh. ncrn,nuncc orrhc truk ftr w[i.h Ihc rcflnir i\ i\\r.d
<br />-lhrm3ndtritlnrinhi.wolkcliconrpcn\ali,rri'aurnnc..rsrtqundbySccli.n:l?0OolihcljborCodc.lorlhe,ralmnai(ofrh, work rorwhrhrhs p.rnit is nsucd M,*orlcn ompcnsaiion insuranc. crri.r ud Inicy numh.r c
<br />Eq.drilrrh{ inrhc p. omumc orrhd w.rk lar whichrhis p.nnn is hsucd.l shrll .or .'nnl.y any PcNn in5n, nnncr
<br />$ rs h hccorc {bjcd r. rhc work.r compcnsarnrn h*s otCrlilomia, rnd Jgruc lhd iil \hould hcco.t subl.tr h lhc
<br />*orkc^ compcnun pmvisiofls ol Sdion 3700 or rhc lihn Oxlc, I stu l. fonhwith.omply s irh rho{ !m!ision\.
<br />W RNING: t,ailurc t' {curc wnkcr' .ornpcnsri.n co\erlgc is lnlawlul. rnd nlall sublccr un cq)ldrtr ro sininal Pcnaltrs md
<br />civil 6rcs up lo otrc hundrcd rh.rstrd dollrs ($|fi).tul). in lddirion ro rtu .on ofconr,tcnslion. dntug.s rs lrovidcd iot lhe
<br />:.:4tIr Cdlt. i' crc{ and.riortrc! { icc\
<br />e
<br />I hcrcbydfinn undcr pcnnlryolpcrjurr rhd I rm ln{N{ uMcr pfuvilion olClrnrcr 9 (.onr
<br />oi rhc a!si',c\\ dd Pro lass nnrs Codc. ud Dylircn{ i\ i'r full ntr.c Md cilccr
<br />sqli, r(xnr url)ivi(i,r I
<br />c""r*.r..,X*
<br />CoNSTRfICTION LFNTIINfi A(iF.NCY
<br />I hcEby aflirnondci Fnaht ollErjurylhal rhcE t a co.nncrkn lcndine rSctrcy for thc Pcrrontun.. orrhc *ork for *hth rhk Fmir A
<br />isucd (Scc. 309?. Civ C ).
<br />AITLICANLIIIIIAAAIION
<br />I hdrby rrilnn undcr lcnrlrt orFrlu,y otrc ollhc Inlnrrir8 d(hrrriox:
<br />Dc'Rririon Pcnnih Asbcnos Noriltdion F.dc.0lRc8ulations flirlc.l0, P n6r
<br />Rcqutcd t usofNotific i..
<br />-l
<br />ccnily riar rhc fcdcr.l rcsul,l ions rcsardins asb€stos retuvll *c nor .trlicablc ro lhn pDj..r
<br />[ "\X|
<br />n, ,n, , "* *"0 ,nt annlicu,hn and {src rhar ihc ahvc infomrhn n conccr t alN tu mnply wirh all c y und counry
<br />vord'nsnccaondstrrctjwsrclatnat"ttrrldinC..n{.hn.nndhcrcbyouliorizcrcprcenit,ivcsorfikCnyondCou.tyrocnrnuPnlhc
<br />!bo!c rrenrioncJ l)n)pcny fN irsrcclio
<br />Appllcanl or ABdl siBnslun:-L ,r,,., t 0
<br />P"*ir"" non," rp.r,r r, Y- V E NrcA
<br />oo
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Ereclion Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Rool Sheathing
<br />Shear Wall
<br />Framinq '"/tv/ 19 -.4-jr'.-,,t/
<br />ln su Iation/E nerqy
<br />Drywall
<br />Brown Coat
<br />[/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Ceftif .
<br />FINAL t0/a/lb -a-rpt Lh*G'dt
<br />Certilicale of Occupancv 7f Urv \!-.,'
<br />Notes, Remarks, Etc.
<br />-)
<br />Ext./lnt. Lath
<br />ItrIJ.'. AJJrc.\
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