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BUILDIN .INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steeli Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulatron
<br />Shear Wall
<br />?/ahs 5tt€{
<br />bt 5r *1
<br />wallD /1 z'c
<br />Ext./lnt. Lath //a -/ry
<br />Brown Coat
<br />rylvlason
<br />Pool Fence
<br />T-Bar
<br />ortEnineer Final R
<br />Flood Zone Certil
<br />FINAL 4 /7a /,t 5AK'(
<br />Certificate of Occupancy
<br />Notes, Remarks Etc
<br />OWNER BUILDER DELCARATION
<br />Ih.rch,alfirnrundcrp.n,lryoa!.riuryth,rImcicmplamnlhcConlmclonLi(cnrLrwforrhcroll.winBrc.sn(sc.70rl5
<br />llusincss rid Prcr.\si.n (hdc) Any Ciry or Cotrnr! whi.I tquncs a p.nnir ro .o.{tucr, alrq. inrprovc. dcmlth o. Eplt ary
<br />* .rurc. nriorln ns tsuamc, ako rcqunclthc amlictr.l l'o! such l]cnnir to lilca siSncd nddm rhnr h.orsh. i\ lrc \.d pur$nir
<br />lo rhc trcvirxrns ofrrr Conrracrors Liccnscd Ll{ rahoflo 9. Conmtrcins sirh Scdn'! rO(X) o, Divhion I of thc Ausinc$ and
<br />Polcsions cbd.) o. rhn! h. o6he i! chmfl rhcrctrom and thcbasis r.r lhc,tlcg.d.rc'npri.i. Any vnnsri(,nofscdion 7tl:lt5 hy lry
<br />rpplicrnr,orp.nnilsubic.Brhc,ppli.antrorcililpcoalryoinormorclhrnrirchu rcddolhn($5u))
<br />-1,
<br />fls owncr ol rlrc !rcl.dy. oi nry c rrlottcs wiih wag$ as lhcir Flc ..nlt'.rsdi{ , wnl do rhr s.rk dd rh. $Mm i\ nor
<br />hlcndcdo.oalcrcdforslc1Sa.7044.ausincsrndPorcst)nsC(xlc:tficCoradoi\LtcnscL{wd,EsnolirDlytr)rnnsi$or
<br />rh.F,pcny wio trildr.r irpD(s rhcN)n. and trho drc\ such worl hims.ll or hcrcltor rhmueh hs or hc. owncDpbyccs.
<br />providctl rhlr su.h mlnorcnf,trh ar n.r ir .nddl or oltt&n li)r crh. lt howcvlr. rhc buiuiu or ifqm,vcmnr i\ $U wirhin onc ytd
<br />ol'coDl,cltr{ rhc owid Buildcr willhrlc rhc hurdcn ol pbvi|8 rhd hc or sh. {lkl mr huiu or inrn)rc lic pnp!-ny tur lhc Nrrn\c or
<br />-1.(owcrofrhcpx)p.ny.umcrclusirclyconrrrcrlnSsirhli.riscrlrontrntrshcoi{rcrrhcFrjccl(sc.?041.Bu.incsxn lhrls*mQ)dc Th.(1rnri.l.fs Li.dh\c t-Ls doc\ not rlnlylo rnowmtoit(,t,c yNh. huild\or nnFrrcr rhcrc.tr.
<br />itrd who conkrcrforsuc[pnrrc.r\wirhiC'onrrkitti.cnscdprrrurlrr'rheConrrcroisl.icctrstiw)
<br />lrn,rr.' n n,l.rsql(
<br />WoRKT'R{' (](tNtI)FNSATIoN
<br />D[C!$AIQ!
<br />I hcrcl,y aflirm!nd$ n nilry ofpdjury on. ofrhc rollowing dehnrionsl
<br />lhv.aftitrillnrxinai.workcrrcrn[cnsmi' nsu'r!c.-r\ rc.]uiErlh]Ss-rior.l7l)r)oirhcl-thor(hd..iorrhcpcrionn .cof
<br />rhc wo lnrshihrhi\ pcnnll t hsucd llly r.ohpctrsari,n i'r\urancc .itri.r rd F)licy truflrhcr rrc
<br />_l ccrrilyrhar ir rhc pcrturnun.. ol rhc *ork tu whichrhk l[ nir i{ i\\ucd. t \hdttnor cnpbrrnrF^on in rny nr imr
<br />{, r io hcconE srbjEt to llf wo,kcn .omp.nvnn hwsofcaliforri!. ind rsrccrhli ilIsh.uld S.\onr hrcdbrhc
<br />*.rkcn compcn\arlotr lrornions of s(riofl rT0o or rhc ljtxn Qdc. l sh.ll. tun hNilh .o dy wir I rhoc rmvnionr\ll\RNlN(; rfittrro kr s..ur. \ork.^..nlI[n\arinn 9\rriec tr
<br />,r.rtr, (lr{i}axio,. In.'d
<br />Aprtfonll
<br />tr lrslrl. ntrd nrll { hj..r
<br />.i\il nre\ ur t, ,tr( hun rcd rho!\xnd
<br />SNri,nr 1076 ol rhc lrhnC!)d.. il rrr{
<br />DECIAA.AIIOI
<br />I lrcrchy nflnh dn{lcr |{nalr} oJ !.rjtny rh{r I rm li.ctr{d und.r I,'ovi\ion ofChrprer 9(m
<br />of rhc Bu\inc\!oDd Prolts\ions (tdc. md myli.cn\. i\ in tull lnrrc r lcilccr
<br />\ rh \r.rion 7rx)i)) orl)n \i1)r 1
<br />q,4
<br />-/
<br />l
<br />,,R;*" 7-/ l, 3
<br />(()NStRlt( lll)\ t_L\DtN(i,\cu\(.|
<br />I hcEhy olltrmu cr Fndlryofpcrjury rhd rhcrc i\ a consrruction hnding agcNr lor t
<br />hsu.d (scc.109?, Civ. C )
<br />nm .c.frh.work for whi.hrhir Nnnir i\
<br />APPLI(:ANT DFCLARATI0N
<br />lho$yrrfianu cr p.ialry oft.rjur, ok orlhu n,lhwirs dc.ldraliois:
<br />Dermliri(nr P.rnrik ask{os Norinc ion rcdcal Rcguldkrs (Tirl. {0. Pad6r
<br />-Rc{tui.cd
<br />lrricr.f NorifLari{,n
<br />l..nilirhri rhc ltdcrrl rcguhrnnr rcBadill8 i\b.n.s rcmolal rrc nor rpnlicablc b rhn F+c!
<br />I.c'1 l_v rhrr I latrc r.rd rl,i\ ippl ic,nnnrr (rtrlrllr hrc i',lo'tr[ri,n, n.or(r I asrer,,..nulywirhrll Cirya Coutrrr-
<br />;::::H;fi::'f
<br />l iltlnU.! \hrri,n' rrkt hrr.h
<br />"*.r**.",r"r,, f (
<br />nlarires ofrhn Cilyand Counryro enlcr uponrhc
<br />-D.,.:
<br />21t'tg-
<br />Roof Sheathinq
<br />Framinq
<br />lnsu lation/Enerqy
<br />Handicap Req.
<br />Deputy Final Report
<br />!h^tnid$illtrninkinrCcnificrlcorConscrrbs.ltln\lrcri,*ortcFcornpcnqrion.rsnrovidcdr'orhyS(lior37(x)ofrhc
<br />ljtlrCrlc.lorlhc pcrfornMccofrhc solk nrwhich rhc p.rmir n hsucd.
<br />0O t-'
<br />t nd.* Adttrc$: _
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