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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE COMMENTS OWNDII lrU!LDI'I' DDLCARATION
<br />I herchy ai&r undcr lcrrlly,,f ncrjury rhlr I !m cxcnll]r fron rhc Conrrrcron t-ircnsc ljs ror ih. rulk,$inC rcasr lsc..7i]rl5
<br />Br\inc\\ and Prores\ion codc) Any Ciry dr Conir, which rcqun s r Fnnir r, .o (fl.r. rlr.r, lnuorc, dcnnnish or aBlt My
<br />nru.ruE. prn b ns Nsurn.c. rko rcquncsihc ll)plicrtrr fd ru.h tf,rnirro lilc r siSrEd (licnrnr rlBr hcor sht t li.ci*d ln^u r
<br />h rh. p(,visn,nr.frhc C.nkn.ttr s Li..nscd ljw (Chd $9. ConnncNirp qirh Sccrion TIXI) of tlirision.l ofrhc Busi'r.s rnd
<br />Pml!$ion\ Codc)orrhil h.orrhc k crcnDr thcrcliom Md rhc hask lorrhc!llcscdcrc'lprion AnylioLri(D.lsccrirrTll.ll.5byant
<br />aprlicanr aor a p.m r r0l'jccr\ih. llplicrnr r. aci!ilpcnrkyofnor mn. rhdn firc hundcd dollars (3500).
<br />-1.
<br />ns ow.crollhc prorEnr- {n nryrnrpk'lcs wili N.scsusIhcir nn...mFtrssri( r. *illd.llr sork nfie (rruisnn
<br />i'.nddl oiorcda for sl. (St.7CV4. Businc$.nd ProLssi( C.dcThcConracror'sl-iccn\.1-a*docsnor{pplyr.{nowmt.f
<br />ric pmncny who builds or inlpohs rh.rc( Md qlx, dds sx.h k{k himsclf or hcrcll or rirotrSh hi\ or hcr o{n cnrdoyccs.
<br />trovid.d rhrr such im,,turcmnh m ml i, etrdcd o. onar]n for snh. ll hoqcv4 thc lnriHina or i provc'tuol i\ {,kl wirhi .trc ytr
<br />orR rl,htion. thc OwEr Buildcr willhovc lhcburdcnofprovinS th hcorshcdkl n, taiu or i,r{'r.1t tnc pmFiy ror lhc puqns of
<br />l.r\ow..rolrhcpn,nn!,amcrclusivcltcontrcrirgsnhli.ciscd.onrmcrrsro!\rNrructrlEltr,,lccr(Scc70,14.Bu\in.\\
<br />and}}tssirnGt.'IncConxicroist,iccnscLrsdocsroranplyr.nno+ncrofnn,ncy*honuiusori'ntturcsrhcrcotr.
<br />and $ho contrck lor \uch pri,J.cB wnh a Cotrtr.rorl \) licci{d [llhuMr nr rhc Gnh.rois Liccnsc kw).
<br />-l
<br />anc&orr lnder S.crion-, B. & P C.lor rhh rca$n
<br />Drl.: o*n.r
<br />]yllatrEBli:!0llfENs rlo!
<br />DEcI.ANdIll)N
<br />I lrrchyrlnrnuBldrp.iilryof t !uryo cof rlrclollowinSdcchr.tiotr{
<br />-lh.!c
<br />oiqillnninr! a Ccniftrorc of Conul ro Sclt lnsur fu sorkcls comFnsarbn. r! ptulid.drorbySc.lion1700ollhc
<br />Lit(r Cdl.. for rhc fdf.rmmc of lhc {ork for whicn rhc pcnnn i\ nsucd
<br />ill nuirl!in workc( .on,Ii.tr\sr
<br />hich lhhn rnril is i\\krl Mlwo
<br />bn insuranc.- as rcquircd hySccrn)n lT0Oofrhc bbnrCodc. fd lhc ,.rf.rnranc. ol
<br />'LcrJ. 'nNr 'n.n 'n.u'ar., 'n ,'nJFrlr! Nn'ttr.rc
<br />l..nrry rhar in rhc pcrroi,Mn.c ollhc work id whi.h lhis Fnnil n nsucd. I shlll 0.r c'nployaiy,r.hon nr rny mrnncr
<br />v) r\
<br />'o
<br />bcconE $tj(l k' rhc workc^'co F.n\,r ion l]ws ol Calir({nia. Dtrd .8rcd rh0r iI I rbuld h..om suh]cd !o ihr
<br />*ortcn.omncnetionpovtioniofScrnnrlT(DofrhcLitrrCodc,l\hrll.f.nh*irhcornplywilhlhoc[ovnions
<br />WARNINC Fuilxr. n, sdcurc workch conDctrsori.n .ov.r.!c is utrlawful. and sh{ll \uhj.ct an cnDlorcr ro citoinrl ,rMlri.s dd
<br />riv'l nnc\ up h onc hrndtud rhou\n&l oll ^ rSllX).(XXr ofcoflrDcnsiliotr. drmuc\ is pnlidcd nn rhc
<br />S(ri,r.r{)7a.lrh. lrhtr
<br />)(
<br />UCI:Nlf,UrcNI&[llrB
<br />DI:UJ-BTIIION
<br />I hcEhy afi.nlndcr pcnrhlofpcrjlry rhar I s'n lienst lndq prcririon orClDpr$ 9 (c{mmkinS wilh Sdkn ?O(xi)) ofDivnion l
<br />of lhc Burincss and PrulcsriorNCodc. oln my liccnq h in fiillfor.c macri.cliB 7o \qt1
<br />,.,. -7/zo/t\<c-c-o:-&ft1l .r5
<br />IOXSIf,IJCUAN.LDNIIING.dGENCI
<br />I hcrch, lllirm undc! pcnallrotp.rjty rhd rhcr. h ! con{d.riJn kndi'rs,g.tuy for
<br />'h. Pcrlormncc oflhc so* lnr *hi.h rhi\ p.rmn is
<br />ksuL{lse 10c7. Civ C )
<br />ti tulca\ NJ'h.
<br />APPI I(]ANT Dr(:LARATI0N
<br />I tf,R{,tnnnntr r l]cdxlry ofpcrJury.trc ofthc nnlownrg d..hrrrnls
<br />l)cmlirion Pcflnils A\bedos Norincrrnin F.dcrrl R.Erhri{,n\ (Tirlc40. Prd6)
<br />Rcqrncd I.(cr of Noriaf,ari.tr
<br />I.cnilirh{ rhc lcderil rcsuhr iotrr rcanlin! lshio\ rcnDrrlrrc nortrPtlicrhlc tu rhn!n,r.t
<br />onlinJrcc\ !nd Slnlc Lne\ rcli(irl (, huildi+ rotrnn'cr on. rrt hcrrn! rurl$rnc 'c|rc{rhrNc{ otrhi\ ('iry rnd ({,unry k) r tr utin rltr
<br />rliorc Mntnnul pol).ny t r
<br />AIpli.rnl or Atrnl Sitnnltr
<br />/1 Z" t<a r/a/ft
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />Su bf loor/VenV ln s u latio n
<br />Rool Sheathinq
<br />Shear Wall ,A
<br />Framing -2E V
<br />)*,tf)LY
<br />lnsu lation/E nergy
<br />Drywall
<br />Brown Coal
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Repon
<br />Enoineer Final Reporl
<br />Flood Zone Certif
<br />/i \\
<br />FINAL {(-l6.ll krg.{"lL
<br />Certif icate ol Occupancy V
<br />Notes, Remarks , Etc
<br />ID/SIG.
<br />SLAB Floor
<br />Ext./lnt. Lath
<br />Poli.y Nunrbcr:-Er csr
<br />-
<br />L,1 ci\ Jdr.s
<br />tt
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