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BUILDING- INSPECTOR RECORD+ srrE-woBK DATE ID/SIG.COMMENTS OWNI'R AUILDER DELCARAIIoN
<br />I hcrcbyrftr ntucr pcmltyof |E jury ll lnmcxcm r'ofl lhc (i, mcro6 L.cn\c Law rbr rhc f.llowins rc .n (src70:ll5
<br />tlu\incs lrxl Prolts\i{rD Codc): Any Ciry o! Counry w[ich requircs u pcrrnir b conitu.r. alrcr, nnprovc. dcnnlish or rcnrir ony
<br />{rucrurc. lrnr ro ih hsuituc. lko rcquiBs rhc.pdtatrr r.r su.h lErnxi fu Iilc 0 si8trcd {lrcmni rhar hcor shc is li.cnrd pu^uanr
<br />ro (hc truv,sn,ns of rlk Conrr.kr\ Li.c.*d Law (Chrflcr 9, Conmc .in! virh Sccrion 70fi) of Divnion I oflhc Eurinc$ ird
<br />fu)fcsionscodd)orihdhcorshctexcmpllhcrciro.r,fldtfubrsisla!lhcrllcsedcxcnrflion.Anyvi,,htionotSNrirT0,ll5htriy
<br />rrpliclnrlor!pcirnilsuhjcchrh.rpplicanrroacivilrcmllyofnormrcrhanfivchuJrtddollr\($50o)
<br />-l-
<br />as o*ncr of r he pmpcn y. ,tr m, €mployccs *irh *i!cs !s lhcir sL conrpcnsri.'n- *ill do llE strk &l th. {tu1m i( nur
<br />imcndcd or olT.rcd fff slc (S(.7Or14. Bu\incs\ rid Profcsn,n\ C(xle Thc A)nkcttr\ Lt ctr* Ltrs do$ rcl otply b Jn o$Nr ol
<br />rhcl)n)Fny *,hr huil&or inrpn)ks rhcB)n. ttr whodocs\u.hwrthimscltorh.r*llorrhtuuEhhilorhcrowncmpl.yccs.
<br />nrovidcdrhat such i'lll)rovcnEnh m nol inicntn or olttEt for eL.li howcvcr.lhe huildine or in]Imvcrnr is v,u rnhin Dnc ltu
<br />ofco'lrplcri,n.rhcOsncrB!ik].rqillhnrrhcb!.iofl'R,lingrh,rlEor\hcdidMrbuiklorinpohrhcl)6FnyfothcJ)Uilb{ol
<br />l. o*ncroirhcF)!.ny.r $clusiv.ly.oftx.ring*irhliccn\rdcotrtnk'Eh.oniru.trhrtR)rlrr(Scc.701,1.Bu\irrsr
<br />rl Blf.sirCodc lhcCortacr.a!Li.cnscLradods , dppl!r. rno$rcr ol|t)tEny$ho buildro, irnpn,vcs rh.rc.n.
<br />h. and $ho .ontricsrorsuchp(Uccls*ilhaOn mclonrli.unsc,iaur\uJtrrt,rh.O'ntacttr\l-iccn\ctjw)
<br />I r r.r.n,tn u .r Sc.rn)a & PC r(tr d1n Nr\otr.
<br />Dutr o*n.r
<br />]!!tBli[&r:gDlrtlsi-u0r
<br />D}ITA.BAI]OI
<br />I hdchy nllnm u cr $nrlryolt,c'iryoN olrhc lnlk)ri'rBtlcclrftl(is:
<br />Ihrycrnd*illminraidaCcnificlr.orconsnrros.lalnsurcforw.rkcs om!..s!rion. is lmvided for bySccrion:lT0oofrhc
<br />titutr Codc- aor rhc Infortukc of (h. woA f(tr whkh rhc Frnrn is is\rcd
<br />_lhavcr rvillnrai ain w.rkctr .onrp.tr\rrion insurrncc, !{ requirci hySccli{nr.r?(x)orrhc l-r}xtrG'dc. nrrh. |ulinn r.c.l
<br />rhc so* for $hich rhi\ pcnnir is isucd My*orkcn onDcn\rri{'n insurrNc .rrtr nid t)licy du rh.r rc
<br />-l.cnifylhar
<br />in lhc Frrbrnuacc oI rhc *ork r'or which rhislcnnir n nsucd.I shrllnorcmpk yrny p.rv,' in dny 'inktv, r\ k, hccoft subici b rhe workdi .omr.nsarion la*\ ofCalifodir rnd rgnc rh.r il I should tE onE suhicr nr rhc
<br />work.n .omtc sari{'n pbvi\ions orScdn,n 3700ofrhc LibrC.dc.l \hill. lonhsilh conrply Nirh lho* pn,visions
<br />WARNINC: I,ailurc ro sccuE e{trkc^ compcissri{nj .ouqlc is ulhelnl. md rhrll subjcct ar ..rtloycr lo sinriml pculrics lnd
<br />.ivil fin.s rp kr otrc hlndrd rh.u\and d.llxr\ (5100.0(n). rddiii(,r h rhc co{ ol.omncnsrriotr. dormAcs as lrrovidcd ln rh.
<br />sccrtr -10?6 ol rhc lih,r Gxlc. i'n.r.d lnd ,nonry s tcc\.
<br />Applicotrl:
<br />UCINIED-CONISACIOA
<br />DEclrl.8dL&N
<br />I hcrhy affirmund.r rcnalryofFrjury rhlr I !m liensrl u.dcr troyhion ofChaprcr 9 (codreftins wirh s(rk)n 7ux, olDilhio.3
<br />of thc Busincs rnd Pbf.ssor$Codc.md nrylicc.sc is in full for.c dcilccr.
<br />CONSIA!EIIQNIENDIIC.{EINCI
<br />IhcrbyaffirnudcrlEnalryofp.rjurythalrhcrcn!consrrucrionlcndinar8cmyror'hcncrrorntr.c.llhj$orkfor*hichlhislirmirir
<br />issucd (Sc.. 1097. Civ. C.)
<br />A.ETUCAIIDECI.AAAUON
<br />I hx{,y uijm u ndcr lEnallyolpcrjuryonc otrhc aollosin8 dchraliotrs:
<br />D.rmliion Pc nir$Ashcsos Norifi.ation li(lcm, Rcgul.rioos flirlc40. Pln6r
<br />-RequtcdGIIeroiNotific
<br />ion
<br />-l.drift
<br />thd rhc iadcrr l rc8u lat ions rcB8rdiry {shcsos rcnovoroc.orlpplicrblc Io rhi\ tmrci
<br />I ccnifyrhd I hrvc rcd rhi\ rmlicrti.n uil n rc rhnrrhcrh,vc iir{r'tuitr,n i{.or.cr Irlrero(rpiywilhtrllCirydtulCou ry
<br />0b.vc nrcntiotrcd pro|xnt ior irsncclionpurF)q
<br />ADpliunl or As.nl Si,t rlrre
<br />Si:t Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Sublloor/VenVl nsulation
<br />Roof Sheathing 7 tble ,t/44/A,tl "DryF* all*atl.*1
<br />Shear Wall -qeJA).,\*/-y'b rl
<br />Framino /'/rb., b* *7'ttt
<br />lnsulation/Enerqy \
<br />Drywall t08
<br />Ext./lnt. Lath \Fr.'
<br />Brown Coat
<br />^o...r,fiv\rP
<br />o
<br />Masonry \
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil
<br />-.-A I 2D,/
<br />FINAL z -l 43rr-c)5
<br />Certificate ol Occupancy
<br />Notes, Remarks, Etc
<br />UFER Ground
<br />I-i.. \c Clas:-l-i.ci\c NUD$cr
<br />D!!( (i'nlrr.l,,r
<br />I
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