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BUILDING. INSPECTOR HECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS Ot{NEN OUILDER DEI,CARATION
<br />I hcrchy nfirn undc! Enairy.'f p.rjury rnrr I tn cicmpr fDn lh. Cont&kts- Li.ctrsc L,q lbr th. lolloBirs ro$n (s$ 7(,ll 5
<br />Bu\nrc\\ !r.l Prcfc$ion Codc): A y Ciry or cou ry shich requnc\ n Fnnil 10 c.trsru.r, aller, nnpn'vc. dcnmhh or r.n n r y
<br />sfl.rxrc. rritr k, ir1 isxdn.c. rko L\tuircs thc rfrli.anr ror lurhF.anil ro,ilc a \isncd slllc'mnl lhur lt or $c is li.cn*d Putrudtrr
<br />t, rh. nmlisnnN of rlr Coit..kn s Li..n$d bw (Chrl,cr 9, Comnr .nr! sirh Scdi.n 7(xI) of l)ivision .l ofrhc Bu(inc\\ rid
<br />PronsrionsCodc) orlhllhcorshc i\crcup' rhcrcriomand rhc ba\is r'or rh. rllqcd.rc {rion Any viohrnr of SNtion 70.1I 5 hy uy
<br />,npli.n.r turr Fnnn srhjersrhc rtpli.rtrrb J.ivilrctrrhyofnornu.thon lirc htrndrcddolhr\ ($5u))
<br />I. a\ o*Nr ol rtc pop(ay, .r nry erpbyccs sirh wrlrs r\ rhcir $k compcn$ion, will do rlr wtrk old rtr slnnE is nor
<br />inrcflrd or oncrud ror &rl. I S(.7(l.l4, Busirc$ 0nd Prorcsnnrs Codc Thc Conrrad.is t,iccnE ljw d.c1 e arply ro ,n .$mr ol
<br />thc IDIEny who hoildr or iryrevcs rtcErn.,i *no d6 qch $orl himscll or hc(.lr or rhn,ulh hk or hcr .wn cnDbtccl
<br />providcd rhar su.h nnpnNmnrs ft Bn in!c(k\t r rllcdl lor slc. la houvcr. rhc bnikliry or iq'owdnr ix $kl wirhin nnc ,tJr
<br />ofcoryldion. rhc Oun.r Bliklcr willhnr rh. hd cnoIpmlingrharlror\hcdidft huih or i.{mvc rhc Imltny for rhc purF){of
<br />I. rr.wnn orrh. phlrny. mr crclusnclyconlruclins qith lienscd c.nlracroF bcon{tucr rhc pn,j$r (s... 7014, Busmc$
<br />3fl1 hrrfcshn Code lhc Conrrudff\ Liccnsc Llw doc\ nor rpply ro u.*nd .r proFrly who hu,lds or i.rProrc\ lhcrcdn.
<br />atrd sho contBch rbr such pmjc.h wirh rco iack,(s) li..n*d pursu l lothcConrrrcrn s Liccnsc lzw)
<br />I rmcxctrlln uiltcr Socbo'
<br />Dule: l)*nt.:
<br />ivoRKF,RS',a )nrPrnLS,rTti)N
<br />ollIir&ulg!
<br />I hcrcb! rlrir r u cr ttrtulry o, |[nuD onc oirhc l.ll,'s f e dcchraliors:
<br />Ihrvcrxl$il1'!rinr3i',rC0rilirrrcolConsc bSclll'Ndtlnrw.rkcr(..nrt'ctsiri(u.!sfrovidcJri)rl,ySc.ri(nrl7(x)olrhc
<br />Lrhr Codc.lhrrhc |Erll,rnrrc of rhc *o'k lar whichrtu pcnnir is i\\u.d
<br />I hrvcrrd willrnrn ar workcrC .onrNnntrion insuruncc..s rcquircd $ySccrbn lTm.f rhc tjbor Codc. tirr rhc pcrlomrncc of
<br />lhc vork ior which rhis lcnnil is hsucd. Mywolkcn conucnsrrion insurancc cricnr*l Oni.y num6n uc:
<br />et'e$Q(
<br />Policy Nunnxr.- lrpnc\:
<br />-lccnilyrharinlhepcnbrmtucolrhcworkn,whichrhi\f.rnriissucd,IshallnotcnPloyanyPcro.i.anyDrntrcr$ rsro h..om suhl..r ro rhc workc6'compctrsorion lows ofCalilomiu. lnd asrN rhd irl \hould hcom rubjcd x, rhc
<br />workc^ otrrFtrs nnr tmvisions ol Scclion -utroolrhc,rtsr Code.Ishall, rtdhwnh.oq)ly wirh lhos,,Dvisnrn\
<br />WARNING frilurc ro scurc *orlcn conpcn{rion cownse is xnhwful. and shall suficr an cnDlortr ro Giniml ltMltrs and
<br />cilil lincs uI ro om hundrnl rhorsanil dolla^ rslfi),fiX)). i. rddir
<br />Sslion:1076 olrhc liii, (-ollc- inrrrc{ rid,tromr'\ rc.!
<br />ngln,n, d,nr8.s rs trovidcd ior rhc
<br />Dote: '*
<br />I h.Eby lllt un cr ncn tyol pcrirry rhrr I ro liensi r'pnvhion ofCh.pr$ 9 (conrnrnciry Nirh Sccrion 7(xxr)otDiviri 3
<br />rcNunhc . tD?klbo,.3!47
<br />I hcEby rfiflnundcr Dcrrllyofpcrjury lnd rhcrc n ! con(tocrion lcndi'rg agcrcy lor lh. !.rfonMncc of rhe work tor which lhk ptrrnir is
<br />issucdlsc 109?. civ. c )
<br />AXPIICANLDECLABAI]ON
<br />I trnJ,y aainn xndcrycndl'y of pcrjury o.e of lhc followinB dslmlions:
<br />Dcmlirion Pernirs Ash.io3 Norincarhn FcdcEl Rceuhrions (Tillc40. Pan6)
<br />Requircd t ncrof NoliaKltion
<br />-l
<br />.cnif, rhll rhc lcdc,Bl Egrlari{'B rc8.rdin8 asb.{os rcmvd d. nor applkDbl€ ro rtis Pn,Fr
<br />I ccdity rhar I hsvc rcad rha applicltion and storc rhar lhc 0hor inlormtion is.orccr I agrero comply
<br />d Coutrr, b cnrcr ut,' r,f,.nlnaicc( nn Srrrc tiqsrliirBk) huildirg rhy a(k*i..*rcedASor $is cir y
<br />,1plrli(ul or A8cnl siSDt'rc 1{r
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />Rool Sheathino
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Ceftif
<br />FINAL 1-3l"lK X.lul16
<br />Certiticate of Occupancy
<br />Notes, Remarks, Etc.
<br />z LOLE
<br />L,
<br />-t
<br />of rh. Busircss rnd Prufc$ions Code. srd my licensc n in tull r'o!e udcfticr.
<br />trn'l.r . \lrN
<br />L'nJ '. 'lJr.\
<br />rluvc nrdnnNd prup.ny ntr i'r\pccri('n tElr\c\
<br />UFER Ground
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