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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNDR BUIt,DER DELCARATION <br />I her.by arrm undd le.alry of psjury rhar I m .rmpr fmm the Contlclo( Licen* h\v for rhe folloNins raon lsd 70l l 5 <br />Ituin6s ud Profsion C.dc): An, Cny or Cou , Nhich r<utr6 a ps' il ro co.st cl. ah6. improq d@DlGn o ctrn mv <br />srrucrB., prior $ ns isu&.c, d$ r.quns lhc applicdl lor such temir io fil. a sisncd stalem€ lhal h. o. sh. b licas€d pu6uaol <br />ro rhe DrcvisioN ollhe Conrocb.s Licens.d Low (Chaptd q. Com,nen ins wnh Se.:1ion ?000 of Division .l of rh. ausinN d <br />Profcsio.s Cod.) or rhar h. or sn€ is exempl lhsc&oh dlhcbarisaorthcallcS.dcxmplion.AnyvioLlionolsctioo7031tbyM) <br />lpplica.t for a p.mit srbj*lslh€ applicant to acivilp.nakyoanor hote thm fivc hundrcd dollds ($500) <br />l. 6 ow€r olrhc p6l.ny, or m, mploy$ trith Nas6 s lh€n sk .o,npNrion, sill do lh€ trorL &d !h. nnxlue is rct <br />imoddj oroltfrd aor ele (Se.70,14. BusinN d ProliseioB Cod.: ThcConrra.ioar L,icd. L.s dod nol applytodosnoof <br />lhcl,opgly who hil& o' inllrovd rhmn. dd vno d(E such wrl hins.lt ot hmcllot rhrouBh his or hd o*n .mplovc6. <br />provid.d rh.t soch inproldo{i d. mr i ddd orofaol aor sk ll howoq. rh. bdildiu or impro!€nr{ is sld wirhin otr. vs <br />olcompkiotr tlE O" n6 auiklq will har. $. burdm ol prcli.8 rhd h€ or sh€ did nol boiu oi nnprov. $. propqly for rh. purpoE of <br />l. fls oMer of rhc propoly. m exclosllely contracl ins wiih licqsd comddo,s Io consiNcl thc lrojd (scc 70'14. lr6m6s <br />and Pnf*ion ( oder'l hc Cd,lrlcrot's Liccns. L,* do.s nor.pply ro an own€r or0r.ldy$ho builds or nnprovct thdcon <br />and who conl.acrs fo such proj*ls wnh a conuacio(s) licosed puBu&r ro lhcConr8clois l-ic4re lj*) <br />latrexcmpt under Sdion .1, & l'.C. t'r rhi! r6on <br />,IAB(DBL(AUt&NIAIIAI <br />DECIABAIIO! <br />I hseby amnn undcr p6ahy olptrjuryone ollhc follo\vins d(ldaln,4: <br />-l <br />have ud rv,ll ,nainrrin . Cdliarcflrc ot CoNnl lo Scll-lN!rc ror $!rk.B con,Penlition, 6 lrovid.d aor b, Sdion :1700 of rh. <br />L,bor Cod€. for lhe Dqtummc. o alh. lvolt for \vhich thc pmil i Lsued <br />I hav. and will maintain wolk.rc comp.Barion insur.nc.. s r.qut€d by Sdion 1700 of th. kbor Codc, for $e psfomEc€ oa <br />thc $o for which lhis pcmil is isu.d My wotkdt conlPds,lion insur c. cdne &d p.licy nuDbtr uc: <br />=*rr1e TundqL|3s<2t <br />[l ccniay lhal in the po aofln.nc€ of rhe {o!k ror *hich lhis pcmn is issocd. I shall nol onpkiy any p.Mn in lny Btund <br />$ s ro b€o'nc subj€l to lhc wortds .oop.Gario. laws o I Caliaomi4 d or@ rhar if I shorld b€com€ subjcl o rh. <br />{ort6 comp€Galion prcvsioE oa setion l70o oalh. L.bor ( odc. I siEll, lonhsnh ohply wilh lho* pNvbions <br />WARNINC: Failurc ro su. wolkm' compsulrio. cov6as. is unl.*atl. dd shall subjet & dnplors ro siiioal F,Elri6 dd <br />.Nil nn6 up ro on hundr.d rtoltsdd dolld ($100.000). in addiriod ro the ion. dmas6 d rrbvided fot lhe <br />hbor Cod.. intqesl d andn'{ 3 cx- v <br />DECI,ASAII(}! <br />I turcby rfftrm uf,dcr pd.lly olnsjury thal I @ li..tr.d udd Fovisiof, olchspto 9 (cotunacine \vilh Scclio.7000).rDivisi.n I <br />of th€ BBin* dd PmfNioB Codc. dd my lk€e is in tull lo(t,nd.ftsr <br />?,iat1q3@ <br />It I AGC <br />qOXSIBUCUQII.ENDING.ACIN.CI <br />I hqcby amm undd porahy o f pdjury rhal lhsc is a conslruclion lcndins aldcy lor lhc psrorl@.. of th. \York for $hi.h rhi. Frhit ie <br />issx.d (S8.1097, Civ C.). <br />AIIIICAALD&CIA8AIIAtr <br />I h6ety dffim undd p6ant ofpajury one ollhe followi.s dsldatio.s: <br />D.,nolirion Pmnits-AsiBrG Norincarion,:.ddalRcsulaiions (rille,10. Pan6) <br />-R.qun€d <br />L€iln of Norili@rion <br />-l <br />coriay ihar rh. a.ddal rc8ulatio6 rcsa"drns 6b6lot rooral ec not applimbl€ lo this proj.d <br />>41 cdift rhd I har. Md lhi! applicalion a.d nar. rhar $e abov€ inaon.arion is cor..l l asrt ro .onply v h alr (' y ad counrv <br />ordina.ccs.nd Srare tnws Elax.s to builJi.gcocltucl authoEc rcpreolariv6 ollhis Cilyud Court ro e.lq upon <br />,'t{tre 'nhri.i.J pa,|rcn) lur irsfdiitr purD.s6 <br />rppri.unr o.,rg"nr Sign"rrr" q( l <br />K m bcrl',1L\{^," rlfHltY <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />ln s u latio n/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL tu0/;e t^,kl <br />Certificate of Occupancy <br />Notes, Remarks, Etc <br />r< <br />L.nderrAd(bs <br />If--r <br />=