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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG,COMMENTS'OWNER BUILDER DEI-CARA'IloN
<br />I hceby,ilirnr undcr pcrolry or pcrjury rh l amcxcmpl liofr rhc Contrcrorf Lircnc L3* Lrrhd rallowinS rc$on (S(?0ll5
<br />Busincs oftl Pn'fc\lnnr Codc) Any City or Coul, which lcquircs . lrnrit lo conio.r' alrcr. iDl'rovc. dclr,ith or Npair atrv
<br />srrucrurc. pri(rt, ir\ issuancc. atw rcqutcathc Jltili.dr tbr such fflnir b filc s siBncd srdcnEnt rhol h.or shc i\ liccn{d Pulsuanl
<br />ro rhc ttr.vhk,ni orrhc conhclor's Liccnsed tn{ (Ch,Ir.r 9. Commcncin8 wirh sc.rio. 70(x) ol Divhion:r or rh' BNnr( rnd
<br />Pmr.sioN Codc) or rhri hc or she n crdnpr rh.r.rrom.fld thc hash lor rhe alLgcd cxcryln,n. Any vnnd norsc.rh ?0ll 5 hv !trv
<br />nlicant lor a prmrir suhjc.(rhc 0Dplica to acivilpenrllyofnot d.rcrlm 6vc hundrcdn.lh^ (S5fi0
<br />!. A owrcr of lhc pmpcrlr. or dy .'nploto\ wirh w!8cs rs lhcn sb co.{.ns,l ion. will do r,E *ork dd $. IMUF k trn
<br />intnncd or oficrd fttr el. ( SL- 1044- Busincs snd Lht ssn s Cdc Thc G)nkrint s Liccnsc LlR docs n.r aPplv to !n owmr of
<br />rhc tmlEny *ho boilds .r i !rews rhcmn. ud sho dms su.h *{)tt hinrcll or hcrslf or lhmugh his or hcr oqn c tllovccs.
<br />providcd rh.t s!.h in{rre$mnh m frn L cnd.\l .r oftEn nr st. lt- hrwc!&, th. huildin8 or in{mrcn..r t $ld *ilhin orc }€rr
<br />ofcoq'lcrion. rhe O*n.r Brild.r will hrw lhc budcn of,rrovins rhJ! rr .r sh. dil M ttriE or iml,mk th. pmFly lor rhc NrI.v .r
<br />l. aloskrofrhe pmD.ny. uncrclusivcly.unki.rtrS wilh liccn\cdconkact s r, .onstrud lhc FDcct (Scc. ?04'1. gunncss
<br />ond PFrc$bnc(.:1hcConlrrtolsl,i.cn\cl,!wdocsnotaprlyro0noqncroinn,Pcn,whohnildsorinlprovcslhereon
<br />,nd sho conrmch ior such rnjc.rs wirh n c.nka.ro(\) Iicc.sL!.1puN0nllo rh. Conkn rocs Liccnsc l-a$)
<br />I rnrcxcnrpr unLlcrsarnin .B &PC l.rrhnrcin
<br />Drlel Owmr:
<br />1t 86E&S:lAMtEdSAfl0B
<br />DECIIXA.IION
<br />Ihcrchytrmrmundcrprrrllyolnsjuryomof rh.followirBdcclar ionsl
<br />IhDvcdxl*rll,Mi ain o Ccnificlrc orcon{.r ro s.lf.lnsutc f(tr rorkc^ con\*nsllion. is frovidcil roi byScclion.l?(x).rrhc
<br />Lrbor Codc. ntr rh. rdroirmrcc ofthc work fir ehth rh. pdmir i! issucJ
<br />Ylhrh 'd
<br />willmainhin s,,rlcr'u,mn.trs. r.tr trrurJtrcc. r\ rcquircd byScdiotrl7filofrhc Lnbor Codc. for rh. l)cdommtrccoi'ri.worllor*hichrhrnc'n{r,\.sumM}w.rkch'lnmncn\Jrtrt1in\u'dn!.canflJndFnicv d rb.ruc
<br />2Q1,r 61.1 4 -1k
<br />C sTSs\loBS 9lt.llE
<br />I cnilt rhar in rhc lcrfoiinrRc oilhc $ork r(, which Ihis l]crmir is i\sucd.l \h llnol cnrDloy !ny F.ison in trnv monncr
<br />qi as r' bc.o'm subicr ro rhc *oik s'conlFcnsorior hwr otCalifomia. Md r8m rhoi itl sbuld b...m subJccl t,rtu
<br />{o dJ conDcnn id I,n,visn,ns of Sccrior :1700 ol rhc litnr C.dc. I shnll. ionhwiih co.Vly wirh rhos pDvi\ions
<br />WARNINC: Frlun ro sure *or*c^ onDcn\diotr .uvcslc is unloNlirl. rnd drll suhicr an ct{lolc. b Lritninal lf,Mlris and
<br />civd nm{ uI ro o.c hundrcd rhonsatul dollan ($100.0001. in Iddirion k, rhc.osl ol conrP.nsdn,n dmB8cs !s rnr'nnd ntr rh'
<br />\.(rrr ll)160r rrr lrtxtr cod. i'n.r.n 0d irkrncv \
<br />,,,",7121!tr a !r2 -v
<br />UlIL,1-B,II.llll
<br />Ihcr.hya,ft nMcr D.nall) otFrjurt Ihd I ir [.ctrlilu.dct nn,lisiin otCh.lrs 9 (connrrncin! $nh Scclir T(IxrorDivision :l
<br />of rhc B!si'k\\d d I'$fcssbnsCodc, d 'nyl'.ctrs. i\ tull lorLr aBlclltcr
<br />A/R qqZtL1
<br />"lzltF if]- lDs &rylslr, {r<-
<br />C()NSTRUCTION ! nNIllN(i A(;I'INCY
<br />I hcrcbylrfirm undcr Fnrhy or,'.rrurr rhd rhcre n a coondcrion h.din8 oscmy nrihc llrrornEn(c olrhc work ltr *hichrhi\ Frmir L\
<br />issucd (Sc..1097. Civ C.)
<br />APILICANLDES.AE.EIITN
<br />I lEtr$y aninn uftlcr pctrdxy ol !.rjuty orc ol lhc lollowins dcclamridFl
<br />Dd.$lir n Pcnnih.Ash.nos Norificlrnin tud&rlRcAulaliotrs (lirlc 10. Pd6)
<br />Rcquncd bllcr of Nolificarion
<br />-l
<br />ccnily rhur lhc acd$rl rcSuhioN Esardins Nhcnos r.'mval ,tc nol aPPlic lc k, rhir proj.tt.
<br />I $nify lhar I havc reud rht rrPli.ation dul sr0rc lhul rhc otovc intormrion is cot.tl lasrelocomtlywnhollCirvttrdCouniv
<br />onii.amcs ard Shlc t ws ElulinB ro btrilding consldcrion. ond hcrchy uxrhoriz. tcPt€rco!,ivca orrhh Citv lnd Cou.(vro cntcr uPon rhc
<br />I rhM rc, tr r,iDm.:n!rd'nnf,cri,nroum'{s
<br />[rr,,."., ". n*.",.,*'.,,*l aL
<br />\,"-u**.",0n,,, d *",
<br />l'
<br />ft.!-+? /z l/F
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framino
<br />lns u lation/E n ero y
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL x-\749 u"v+14
<br />T-Bar
<br />,/r-r\
<br />Certilicate of Occupancv
<br />Notes, Remarks, Etc.
<br />trndcl\ tiam:
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