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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDAR DELCAR TION
<br />I hcrchy alfirm u.d.r pcnllr, of lcrjury rhd I dh.rclr,|)i liorn thc Conta.roF Li.ensc Liw tut rhc rdllowins rc!$o (se?011.5
<br />Busincss nftl Pn'Icsion Cndc) Any Ciry or Colnly which rc+irs tr Ernril h co ntu.r. rlicr. nnlrovc dtrolirh or [r n anv
<br />(ructure- t rt) ir\ issDnncc. alsorcqlircsrhc aPpli.r.r fd suchpcnnil b fil.r si8ncd st cmnr rhai lror she is liccn\cd lt rsurrr
<br />to th. tmvisionr ol lhc Conrru.rors Liccnscd L!* (Chlprcr 9. crom,Rncins wirh sc.rnD 70(x) oI Divi\i'n I oi rhc Businc* tud
<br />Pr.fc$ion{Cod.) or rhal h,.rshc iscxcnpr rhcr.iioNMd lhc b$n tur rhc,llceud crcnll]ri{in Anv vi.hrn,nofSccrioi 7o.ll5 bvonv
<br />rppli.rnr rdap.rnrn subjccrslhc attlic.trrb!civiltcnlhyotnornnRrhinfivchundrcddolltrs(5500)
<br />-1.aso*ncrorrltPlo|rny.ornycmlloyccswirhw,8cs.\rhct\olcconrpctrrdio..eilldolt*work
<br />xl Lh. ntulurc i( nor
<br />i .all{ or off.rcd f.r Rrlc ( Sa.7or.t, Buifts dtul Pn,fc$ions G{tc Thc Conta.kn s l,iccn\r Ltrw docs nol ll)Ply b u owncr oi
<br />rhcpmli.ny who builds or ftpov.s rhG)n.,frIwho dm\ su.h qo& hin$.lfor hcrsclfor rhmuSh his or hcr osncnlplorccs.
<br />ptuvid.dthrrsu.Inurovc.nbucniinrcncdoroflcr.dlbrs"lclihowclcrilrldildingori'nPnrlc.nnrissohvithinoicltru
<br />df.u VLrk[ rlE Owncr Buikler sill hjt rhc hodcn ol I'Dving rhi nc or shc did mr bnikl or ilqrok rhc onlrdy for rlr puqx)c of
<br />l,rsoqncrolthcpmpcny.rBcx.tusivclyco rrctins $irh li.cnsdd.o racror b connfld thc n r)i.! l Scc ?041. Bunncs\
<br />and Pinls\i,tr Codc: Thc Conkrroi! Li.c { l-iv docs trot rPnlylo!no*ncroffm!.dvwh{r h ilds or nnPtotr! rhcr'on.
<br />rtul whu .o.la.ls ior such p'ojc.h sirh i Contucrqls) liccn\cdlu$urnl hthcAn tu.ttr s Liccrsc t,aw)
<br />Irtrrcx. r|n utrdo Sc.ritn,
<br />D6I.: Owncr
<br />wotxFlrs;(tlItPtt[sA rrcN
<br />DECIAXAIII}N
<br />I hcr.ny afinnundcr penalryorPc.iurronc olrhc blbwi',B dc.hrnriotrs
<br />Ih.vcdisillmainloinaCcni6.0rcofConscnlloSelflns!'crorwotkssconrFns.riotr0slrovidcdrorhtscctionlTlirofrhc
<br />Ljr$ Cod.. ror lhc pcd.,roncc .r rhc *ort ior which thc F mir i\ i\sx.d
<br />-l hr{ xitl sill .iri'nair workcr' conEn\ trtrt irr\ufurc. .s tcqu in(l hy Sc.rn, r lTlx) oi rh. libor Gd.. lor rhc Ix rr'nn'ft' ot
<br />rhc *ork r(n ehi.h rhis prnnir i\ i$td Myworkcrs'comDcnriri{nr in{nncc.rnicr ifrlpoli.ynu rbcr iuc:
<br />I ccnilirhal in rhc p.rntrmm. orlhc sork lor *hichrhi\ Fnnn i\ tsucd l \hau nol cnplovrtrvlr.6on in.trv.Dnner
<br />e a\io b.{om {hjer ro rh. Norkcn d,nl.trqriotr hws ofcaliiomia- ntul aeNc rh ir t shrld tx.onE sunjd rorh.
<br />*orkc^ .o rpcnsdrn,nln,vkioNol Sc.rimlT0Oolrhc l,rkrCdq l {hrll, Ionlrs h cont,ly w(hllDt Povisnnx
<br />wARNIN{: I'rilrr x, {ruir' sor[ur\ cotrr|{n\xriIn, (o\eIn!( i\ trtrlirlnl. rtrd \hn!l hlc.r rn .'npk)yd k, c'i,niml |rLmhic\ rD
<br />civ'l 6nc! uD k, onc hud'lr.d th($d-, x176,,f ,t r"L.f,,,r. tr
<br />,.,.,
<br />" /30l!!
<br />iu\trrl i[n],rl rllrr,.rrrrr trr ll'llr il ns.iilrn.,Ii]r!c\ r\ |rrnlrJ
<br />ull}urlll]Nlts1!rc8
<br />DI.:( t.AR,\t l()N
<br />I hcrby dllirn unrlcr pcnrlryol l,criury I crp'o\i1idrol(hrfl.r9{.o nrtn.in3\irhSccrn rT(xx)).1l)i\i
<br />of rh. Btr\itrcs\ind Pnnc$io'r Codc. anl trryliccnsc is h lull f,ncc frlcllccr qv63s4clo
<br />D"t,]p (
<br />I hcrchy rflirnrnndcr pcmlry or ncrjury th0r i\ r.on{ru.ri( lctrdif! rS.tr.) 1,tr rlt tDtnnn!Nc.r,h. *u* lor "h'.h rh'. |xirnir i(
<br />i\\uod lsc( l(I)7.( iv C )
<br />lrndri\ ddr.:!
<br />A.ELT$NI.DEELABAIION
<br />I horhy rllrD undcr pctralry orr.rjury orc oilhc roll{'*ing dt.lrrariotrs:
<br />Dcnhlirirn P.irnir*AstEslos N.rincarrtr FcleEl Rc3uhlion\ (Tnb 40. Pd6)
<br />Rcrtuircd I!xcrol Norilicdkrr
<br />ridrs rclardirarsttr\losr.nn,klx'. nor q,Pltrhlc ki ihh lojccr
<br />)vc infornurt,. ir..rsl.l lrre t, cor
<br />cJ-n r, -r/',r., rt"
<br />kel,t
<br />I hc.cby .ulhori^ 'cprosc nlivcsoIrhis
<br />y'ro'\d QYL
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Itilason ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certif
<br />I
<br />FINAL ?\z\\\s /.u4tI,ICertilicate of Occupancy
<br />Notes, Remarks, Etc.
<br />Subf loor/Vent/lnsulation
<br />fl
<br />lC9Ar.
<br />Policy Numbc,:-Erircsr
<br />-
<br />f-- T
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