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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE IDiSIG.COMMENTS OWNER BT]ILDIiR DEI,CARATION <br />I hscby aflirm uhdd poralry ol rEju,y lhal t d .x.mfl lmm rhe ContEclo* Licaxc t-a* i.r rh. follosins r@)n (s- 701 I s r <br />BusinBs md Profsion Codc): Anl ciry or Cou.ty which r.q"t6 a p6hn to .oNrtud. alts, imrr.*, danolish or r.pon dv <br />srrucrE. prior ro i|s issu.€.alsor€qut6rh€appbcanrforsuchp.nnnlofilcasisn€dslardndtrhdheo!sheGlic.6cdpusudt <br />Io rhc prc sioN of th€ Contactois Lic.ned Law lchlptd s. Com6..cing $ith Selion 7OO0 or Divi.i.n I oflh. Brincs md <br />Pmf€siotrCode)orlh6llEorsheiscxemflrhdefro'nadlh€hsitforrhealle8ed.renplion.Anyriolationois6lionT0ll5branv <br />applicanr for a p.mn subjNBth. applica loa.ivilp.oalryofnormorcrhelivehundrcddoll&s(1500). <br />l. 6 o*no of rhc propcny. or ny e'nployc snn Nas6 6 thcn sk comt Mion. Nill do lhc sotk dd d. sNlrc is n.r <br />inhded or oftcrcd for hlc (Sc 7044. B6in6s &d &ofsiod ('ode The Conlracror s Lic.N LaN do6 not applv ro m ovncr ol <br />rh€ poFn, sho hrilds or impov6 tdon, s.d who do6 srh tr!* hiruclr or hm.lf or rhrotrsh his o, hd.$ n .mplovc. <br />provid.d rhar sucl nnpsvdndts d€ nol htdd.d or olldld for s.le Il hotrBo. $e hdildin8 or imlhvmdr is $ld * ilhin on. )d <br />of conplaion. rhc 6rnn Boil.ki wiu hav€ lhc trrda olprovins rhar h. or sh. did mt hild or iDpmr. rh. FlFnv aot lne p{rFe of <br />-1. <br />s oM- of te proFny. dn crclusivelycontacrinS $ilh lic..s€d coniraclo6 to codtuci rhe Imj61{S< 7044 BBms <br />dd Plof6ion Codc:1hc contradois Licens. Law dos ool applylo d oN6n ofpropdy Nno builds or nnProv6 lhdd.. <br />ed who co.hds lor such proj..ls *ilh. Cod€do(r licas.d puslanl lo lh.aonlr0clois tic$c li*J <br />I on.x.tr,fl u rld Sc.rio <br />$4Aa6I8S!9U[E!SAIIA! <br />DICI,ABAIIAts <br />I hn€by amrm undd rEnahy oarEjury onc oathe lollowins d<l&liod: <br />-I <br />hav. md *ill mifllain a Calii.ar. of Cocal L S.lf-lsurc fo, $orkdr onD.nsln n, 6 p.ovidc.t aor b, Sation 1700 of rhe <br />Labor Codq lor Oe pdaonnmc€ ollhc sork fo! $hich rh. pmil k ireu.d. <br />I havc and will'nairlain wo ert conDcs.lion isur.nce. s requned brsalionlT00 orlh. Labor('ode. for lh. pdfonndcc oa <br />lhe Nork lor *'hich lhis ponit is isu.d. My vorke( comlENrion i6ure.c cMis ud [rrlty nu 66 dc: <br />M '."1 W.rr. I t*a 't* <br />lisrtl p1-r221) at O*/ r.\Q <br />-l <br />cftrry Oar in Ihc pdloDndc€ olllevork fo. shich rhis Pdmit i5 issucd, I shtll f,or dnploy my p6on in any mannq <br />e s 1o balm€ subjdl lo lhc {ort6' comp.nslion laws of Calilomit. ud a8re lhal if I sl'ould L.od. subjat lo th. <br />sork6' omp€nstion povisioB of Selion 1?00 oflh. kbor Cod.. I slDll. aonhwilh coniply *irh rhoF prcvisions. <br />WARNING: F.ihr€ to suc wo,k6' codpoMrion covmsc b onLrvtul. dd shall s!6jd o 4plo)a ro cimi.al FEhB ed <br />.ivil an.s up to one hundred lhoNand dollos ($IOO,OOO). in addilion ro tb. con of conpccdlioh. damsd 6 rrovilcd for lh. <br />serion 1076oithc l,bor Cod., intn6r d altomey s lc <br />I h@by amd undtr p.ntlly of psju.y lhal I d lic.ds.d trnds Pro\ irion olch.ptd 9 (.onmdcins {ilh Sedio.7m0) orDiviiion l <br />ot th.Bsinssd Psfeioro Codc. od mylteG a in tull for.e and eiI(t <br />G '.4O44 q.-lw-tE* <br />CANIIaICIII)ITENDIUC.AC!!.C} <br />I hceby afirn rndd p.n.lry o i psJury $a1 lh@ is 0 oislruclion Lndins aga.t lor lhe Dsfomdcc o arhe sort lot Nhlch lh6 Fnil is <br />issu.d (S( 109?. Ci! c) <br />AIIU(ANLDEITAAAIIO! <br />I hlq atrm und6 paal', of psjury on. of th. following d(ltralionsl <br />Demolirion Pdnils'asbsros Nolificalioo Fcd6al R.gulario.s (Tillc 40. P[lo) <br />-R.qun.d <br />tiid of Nolifi calioo <br />-l <br />cqrify rhal rh. fe&ral rcBulalio6 rerudins dberos r@ov.l m noi applicablc ro lhis projd <br />Ef(d,b rhd I h,'c rcJ,,rhtsoppl <br />-orJindc6 dd Srar. Ln$s rclrin! lo <br />icalionsdsrarerlftlhc lx\r i,nnnnarnD N ro'r{.r I i!'ebcotrll]ly\rihall( 'rtrtrd( otr01) <br />fid.by auihoriz. r@.6@raliv6 o f lhis City dd Cou.ry ro dl6 upon lh. <br />.hve rne ioncd p.oFny ror <br />,\0pli.onl or AE€nl SiEnNlure <br />"( <br />A <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Brown Coat <br />lvlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL hjul'l it\/{ <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />Subf loor/VenVlnsulation <br />Ext./lnt. Lath <br />,,,,",Nov1520tA <br />,llw I 5 2018 <br />I