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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDITII DELCARATION
<br />I hcrhy rftrm ukhr pdml(y of pcrjury rhd I dn cxcmpr trofr rh. Contrtn Lkcn* bw frtr thc nrlowidg rc$otr (S( 7011.5
<br />Busim$ alld Plofc$ion Co{ic): Any Ciry or Counry trhi.h Equncs ! pcnnn n, con\rrucr. rhcr. nnorovc. dcnilii\h d Elan uy
<br />dtu.rur., priorr. its is Dne. rl\o aqunrs rhc aplli.a.r tu su.h pcr.rir k' filc r \ig(d srlremnr rhai hcor {h. h lieni.d pur$rnt
<br />lo lhc trcvhio.s olrh. Conrr&toas Liccncd trs ((]laptr 9. Co,nmcftin8 pilh Scclion ?(D0 of Divhion 3 oflh. Businc$ and
<br />Pmicssions Codc) or rhal hc orshe h cxcmpl lhcrclrom and rlrc Msis for rlrc trllcgcd cxcnption. Any viollrionolSEriooT0:ll5 br rny
<br />4pli.rnr a.r a F.mir \xbj(k rhc rppli.anr ro a civil p.nalr, oa nor nne rhd fivc hudred dollas (stm)
<br />i
<br />-1.
<br />d. nrrEr,rrhc noncn). n mycmnlo)ccs * h wJFc\ a\ rhctr $lc $'n'rrrrri.1. *illdu lhr *ol and rlr {trtm i. fr
<br />i,ncndcd or ofrcrcd i.r slc lse 7044. Bosincsa and Pmlcsions Codc: Thc Conr0ck,\ Li..trsc hw docs nol srl,ly lo rnoNncr ol
<br />rhc pmpcny who builds or i'nJtros Lh.mn..ild who dds such sork hinrs.lfor hcsclfor rhmugh his or hcr owncmployccs.
<br />,rovidcd rhrr such impmumnrs are nor inrendcd or ofcrcd for slc. Il howrq. rh huihi,r8 or impmrcmnr is sld wirhin om ,tu
<br />or co'nplcri,,n. lhc O$ner Buikler lill h.E lhc bunlcn of prcvin8 rhar rs or \h. d iJ mr buiu o! inDroE rhc Fnpcny ror rlf poqms or
<br />l. \os crolrhcpmFny. n.krlu\ivclycoDttrcri'Usirilic.n\cdrotuarbnt,c.D{ru.rrlrtnir..rlsd.?04,4.ltusnc$
<br />0nd l'llit$hnCodc: l'hc Conlr[lols Li.ctrsc lrw do.s nor ipt'lyb ovn.rolfmpcnywnohuildsorinprov.srhercotr.
<br />rnd who conrrlck ftr such prr)cch sirhr Conractln 9 licco{d pu^u t, rh. Cloitu ktr\Lt{nstjw)
<br />,"rr'l/l /a,
<br />I hcrcby.rftDr ind.r pcn0hyofFrjury
<br />I lurr *rlwill trDidrir rCdnifi.rrcofCon\cnrt,Sclalnsrrc for workc^ .otrrp.trsdn)n. Js providcd lbr [ySccrt,n:1700 ollh.
<br />llhor Codc- lor rhc Frfomn.c ol rhc wort tor{hichrnc pcrmir n issucd
<br />I hrvcnM willmainrain w.B.ri.omp.dsarn,i insuhn.c. r.qxiBl hy Scd ion ll(x) of rh. ltrhor aidc, lor lhc Iarlor rurcc ol
<br />ihc *ork foi whi.hrhi\ pcnnn is isucd Mywork$i conlr qrion i.sunmc.ffiicr flxI Fltynumhcruc
<br />721drryrh.r r rhe l,crlo,mncc or rhc wo,t ru whichrhis pcrm is isslqt.I shatl.or cnll)loyao,Frson 'nanynmmrs' ,srob..o tc ruhjc.r ro rhc workc* co'npc sdn hws .f Crlifirnir. aM tr!rccrhd ifl should tuconE suhjccr lorhc
<br />r.rkcs ..nD.nsarion provi{ons oiScdion lTU)ofrhc bt rCodc,l sh.ll.lonhwirhc.mpl} wirhlhos nroi\ionr
<br />WARNIN(| l-ailulc ro Buc q e( co rI.nsxriu, rovcrugc is !trhurirl. r' $rll \ubjc.r rn cDDloycr tr dinntrd pcMhic\ atrd
<br />.'!il lnrc\ uI r, om htrf,tl'cd iho0\1dd d.lhn (tl(N).lxX)). i', aJnil rhc.orr ol.omFnerion. dlmBcs as rnvidcd nn rhc
<br />:"::tjtryL ,nDDri.nl: X-tr7/Lx/,
<br />t)t.t t.1R,\tr)\
<br />I heEhy alfirnuBler pcrulryoalr.rju, rhar I ad licenBl !ndc, ptr,ltion ofChlprd 9(comnrncing wnn sccrion TsJo) olDivhtun l
<br />ol lhc Busilcs Md Pturcssions Codc. dt my li.cnse n ir full fom .,rl cf.cl.
<br />(IINSTRU(:TI(IN I ENDIN(; A(;ENCY
<br />Ihcrelrya irnrundcr pcnrhyoipcrjuryrhrt rhcrc isiconrrucii.n lcndinsrscrcy ttrlhe pcraorMocc.rrhc *o r(r whi.h rhis frnnn a
<br />irsucd (Scc 1097. Civ C.)
<br />lrtusaNll)lrclrr.Erl,.x
<br />l [rby umnnundcr prnulry ol'pcrjury onc oirhc nnk'wir8 dcch(ion\:
<br />I)cmoririo. Pcrmirs'Ashcslor Norificrrion fcJeral RcBul nns ( lillc 40. Pan6)
<br />-Rcquncn
<br />Leucr ol No{ifrcarhtr
<br />,lc.nrlyrhrrh.l.d.Elmeuloron!rgard,lgd\b.d.\'rmvrlorcrrdptlrftlcrorhtrpnrclrL,, lccnrlyrhd lhxlc rcod rhh rpplic ion sri (,r h.Ih. abov. inlormrion n coE.d , l8re lo omply wirh all Cnr ud Cou.ty
<br />odi,DD.cs Md Slrlc Lar\ rcbrin8 k, bu
<br />,h.v. rctrri(ntrd fR,p.ny f{r npc.ri.n
<br />Apl,lirul 0. ,tcnl Si,tntrltrrr
<br />iklirS cotr{rucri,)n. nd h.tulry rur,nrizc ::::4;W
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />Roof Sheathino ilzt/tt ,.fif/
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certil.
<br />FINAL a Wa*'tD..'
<br />Certificate ol Occupancy
<br />Notes , Remarks, Etc.
<br />-)
<br />Erection Pads
<br />T////? F.
<br />L.trd.is N,,nr
<br />tt
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