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DEPARTMENT OF COMMLJNTTY&DEV�LC►PM�.NT SERVICES
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(909}839-7020 Fax(909}Sb1-311'7 Building Inspection Hat3ine{9i39}839-7027 P�SS
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� I HEREBY AFFlLtM UNOER VENALTV Of CEFUURY TH/f/THERE IS ACONSI'RUC710N LEHOMQ AOHNCY . � � .
d FOR hiE PEIiFORtAMICE UF THE Wo[M FGR WtitC�i 7HIS PfHLttT IS�SSUED iSEC.a07T.CN.C.y.. �
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� lEtiDERS NAiA£ _ , . �_,_
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� 'I CER7IFY TiAT 1 MAYE REAG Y}!6 APPUCATION ANO STATE h1AT THE MWE lNF4AMATqN�9 CORHEGT, �OTAL F i.:EaJ F ! C��Y' ;�(/�
� t Ai3REfi 70 COMGIY W{iN ALL CtTY AND COUNTY ORDtN.W CES AN8 SThTE U'NB AE1,tTWti TO flUR.D�NQ
CdNSTAUf.'TION,AND NEREBYAUTHOR12E REPRESEN�ATNES OF TnS COUNi'Y TO 9lTER W'ON 7HE
z J�BS�VE-NSN7i0FtEII PRUPERTY K1R fN5PECTKTN P41RPO5E5. , COMMENTS
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� RECi'T.NO._ PAiD BY VALIDAYION
WNITE-Degartinen!Cqry,YELLOYY—Fins�ce Capy,PtNK—Assessor Copy.GOIDENROD--File Copy.6FCEFN—Ap�k:anYs Copy
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C;R�:)UI�O PLl!i��iBli•IC I i t1fJf�cR FLGOR COMDUIT
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SLAB GRADE _ __ .T FI�,E?LACE FOU(�DaT10�1
-----�— ----------------� - ----- -- �--_-�-
TEMP PO�VER 'FIREPLACE BOND BEAM
��IATER SERVICE 'NIID HT.BO�ID EEAM
ROOF SHEATHItJG � '3 ;3 FT.BOND BEAM
---- — --
X FRAMING/VENTILATIOM- - ---I--------- - -------J--- - ---- I FIMAL BOfJD BEAM------- ------- -
ROOF COVER , \ 'PRE-GRADING
----....._-----...____ __..----__ -3- ----- ----___ � ------ ----------
ROUGH HEATI�IG �BEfdC�i!NG
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ROUGH ELE��fRIC ' �ROUGH GRADING
ROUGH PLUR�161NG �FINISH GRAD�NG
SHOWER/TUBTEST I p00L ELECTRIC
EXT.LATH;SIDING � I � (POOL FENCI�G
�VALL I�ISULATION j POOL FINAL
CEIUNG RdSI ILATION �OFf-SITE IMPS.
DR'(��1/ALL Pd,aILING � � � i DEDICFITIONS
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�EWER � j FINAL ENG.
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SEPT1CTAtJK I LANDSCAPE/1RRIG.
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SEEP PIT!L.L. I OPJ SITE IiV1PS.
GAS F�IR TEST I FINAL ZONING
FINAL CONST. �FIRE DEPT.FINAL
FINAL FIEATING �HEALTH DEPT.fINAL • "" �
FINAL ELECTRIC DEV.FEES PAID
FINAL PIIIMBING I EMERGY � -
FINAL PLANING
FINALENGII�1tERIMG ' � �•,r�,:.a !�
COMMENTS b �< < � n u a� 1 a'
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' Attachment A
Form for Non-Franchise Haulers for Construction and Demolition R.equirements
,
Company and Project Info:
Name of licensed demolition contractor hauler or self hauling cornpany � �� ��!��g F��.N( �
Address of Coznpany City
Zip Code Phone Number
Address and Name of Project Site � ,
Type of recycleable material or waste material to be transported for this project
Report Information:
Please submit this information prior to final building inspection. .
A report reflecting the following information:
• The estimated volume or weight of construction and demolition debris,listed for each
, material; �
• The estimated volume or weight of construction and demolition debris that can be
diverted listed for each material;
v The estimated volume or weight of construction and demolition debris that will be
landfilled as waste; and
• Identification of the vendor or facility that will collect or receive the construction or
demolition debris.
AB 939 Fee Payment:
Pay AB939 fee of$6.00 per bin and$40 per roll off for all non-franchise hauler containers
Type of Container number of container
Paid date(o�ce use only) (revenue code CD Waste)
Agreement and Signature:
The property owner agrees to submit documentation to demonstrate compliance with the 50%diversion
� requirement for construction debris and shall indemnify and hold harmless the City for damage and
liability, including any financial liability, fines and penalties, associated with using a non-City
franchised hauler and failing to satisfy diversion requirements.
� �-. /.�f�rvi�c_ �CT�v�64� l2 �6 �
2 .
Property Owner Signa e Print Name Date
Self Hauler Signature Print Name . Date
Last updated March 14,2008
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Los Angeles Uniform Code Program ,.;��-�-������wa
Uniform Procedure 1-7: Special Inspections 'L:�►�UC�
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e S�ESIAL IidS�ECT60BV R��O�Y .
❑ DISC�EPAR9CY � COP1�0�4ADtE
AU discrepanaes shaH�,be braug�t to the inur►adiate aibention of the H wak oonfom�to appro+red design and oode re�iremenis�.Submit this
Contrac�or ior caRection. H oarecUons.are rs�rt�ede fn a tim�y rePat to BuWing Oepartment and Fapies�Contractor�Erx�ineer/Architect
manner,this report shall be used•as a.discrepancy notice. Subm� of recob. and Owner rro later than the bu.siness day tdloadng the
the original b Bw'Idng DepartmeM �d copies m Contracbr, conc4uslon of the speda�inspe�fon.For inspections greai�than 5 days
EnaineedArchitecc;!oi reoord�d Qwner.. dura8on.submit a coniormance�eoort at least once everv week.
This is.a: �-P. ress R ort �Flnal Report R No.: Page Na � of �
.�� ' S' lf/�E�s S /�� �0"a a��,.
2�d " ���-d� � �iiz� ��� /����-
� I�huMer . nser d Reoa� CaMreaor.
�t/L`�(/� ��/�'" ��C-�/ Pc�rtoc-lE�r/ �' '.�.
�fl Nams SPeda�I�pedor: , Replatretla+N�untie*: N�rnber:
r/.4� �u Po +y-��' � l/�/��r • 7�s�- �f J-�'�.G �
Type.ot In�pecUon:
�Reinforoed Concnete �Structural Masor�ry O Piling,Piers and Caissons ❑Smoke Control
O Prestressed/Post-tensio�ed ❑ Bofls in Co�crete/Masonry O Excavation and Fills ❑ Energy Compllanoe
❑ShMcrete/(3unite ❑SWdurat Wetdinp O Spray,Applied`Fire Prooflng O TesHng Reports
❑InsulaUng Conc.�et�/Gyperete 0 High Strength Balting �Other
T1me Time .
� Miv�d Depa�ted Des ption and Locatlon oi Work Inspected ��� ���'�� ������
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1 HEREBY DECIARE THAT THE FOLIOWING IS TRUE 70 THE 9EST OF MY KNOWLEpGE:
1• � AM. OR MY COMPANY IS, RETAINEO BV THE OWNER OR THE ARCNITECT/ENGINEER OF RECORD TO PROVIDE SPECIAL
INSPECTION FpR THE WpRK COVERED IN THIS REPORT.
2. 1 HAVE.PERFORMED THE REOUIRED INSPECTION DURING THE TIME PERIOD AS STATED ABOVE.
3, THE YVORK COVERED IN THlS REPORT IS,IN CONEORMANCE TO THE APPROVED PLAN$. SPECIF{CATIONS AND APPIICABLE
WORKMANSHIP PROVISIONS OF THE CODE,EXCEPT AS INDICATEO OTHERWISE.
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