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#0724-RC0201-01
Supplemental Questionnaire

Last Name
First Name
1.

PATTERN I

Describe at least four years of experience as a journey-level carpenter, electrician, plumber, sheet metal worker, warm air heating, ventilating and air conditioning worker (HVAC) or journey-level crafts worker or as a contractor in one of these fields.  Include employer name, job title, dates of employment, and a detailed description of your duties.

1a.

PATTERN I Substitution

Completed coursework at an accredited college or university in building technology; civil, mechanical, or electrical engineering; or a closely related field may be substituted for experience on a year-for-year basis to a maximum of two years (30 semester credits equals one year).  List the name of the school, the courses completed, and total number of units completed:

2.

PATTERN II

Describe at least two years of experience as a construction inspector for a public agency, whether as an employee or in a contracted capacity, which involved inspections experience in residential construction.  Include employer name, job title, dates of employment, and a detailed description of your duties:

3a.

FOR BOTH PATTERNS

I have read and understand that incumbents in this class shall complete one year of verifiable experience in the appropriate field, and shall, within one year thereafter, successfully obtain the International Code Council's Combination Dwelling Inspector, Uniform Codes Certificate.

Yes No
3b.

Possession of a valid California driver's license is required.  Provide driver's license number and expiration date below: