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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BI,]II,DF]R I)EI,CARATION ..' <br />t) lhc provrsli)ns ol llrc C()nlrnclor's l,iccnscd L{w (Chaplcr (). Conrnrcncing lvith Sccli(rl 7(NX) ol Divisir)n .1 ol thc Btrsincsi antl <br />{pflic{ntti)raFrhitsuhjcctsth!'all)licxntlorcililpcnaltyolnriltrn)rclhilnlirehunrlrcrldollars(5500). ( <br />salc). <br />_1. xs owncr ()l thc I)ropcr1y. {nl crclusivcly crnilracturg rvith l,ccilsc(l c()nlrael(n s l() conslnrcl llN pricct (Scc. 7(H4. Rtr\trlc\s <br />rnrl who u)nuicl\ ll)r \u(h pfi)jc.ls wilh i Corilraetnl\) liccn\cd l)urs[rnl t(, lhc (i)nlrilclor's Liccn\c Law). <br />I ilnr c\ctrrpl un(lcr Sccli()n_l|. & l).(. l(n lhrs r.t\,)r. <br />lhlc:- <br />IYoRKUI(S' ('OMPENSAl'tON <br />I)ECI,ARATI()N <br />l hcrcby al, irnr undcr pcnxlly ()l l{iur-v rn[ ol thc lol[)win! dccltril ii,rls: <br />_l hnvcarilwill manrl{inaCcf,iliertcofConscnlloScll:ln\lrcli)rw(nker( coilr|tn\at()n.rs prolklcdli)rbyScrli([.17(X)ofthc <br />l,rtx)r Cixlc, li,r th. t-*rlornunce ol thc work for which lhc l-*nnit is issucil. <br />lhc work li)r which thi\ pcrmil is issut-d. My wrkcrs c()ml)cn\al(,n lnsurrn(. cntricr rn(l F)licy lnrnlhfl'arc: <br />( <br />I'olicy Numhcr:_tixpircs: _t <br />_l cerlily lhal iD lhc pcrlarnuil(c ol lhc work liil whrch lhi\ fcrnril is rssucd. I shall nol cntpft)y any f^-rs()n in any nrrnncr <br />\r) rs k, hcc()nr suhjcct t) lhc w()rkcrs'conlFnsalii)n hws ol Cxlilirmia. antl egrct' that il I \hould huc()mc suhjc(l k) llE <br />work(a'\' cr)mlNn\rli(rr provrsrrns ol Scclir)n .17(X) ()l lhc l,xlx)r (\xlc. l \hall. litrlhwilh conrply wilh lhosc prx isirrr\. <br />!ivil lircs up lo onc hun{lrcd lhousarrl rlollars (sl{)(1.{){)l)). in l() lhc c()sl ()l conrJ\-n\xtion. (lxtrlrgcs xs il()vrlc(l li)r lhc <br />Sccli(n -l{176 hc I.alxrr (ixlc. rilcrc( rn(l xllnnev l l('c\. <br />I <br />I herchv allirnr un(lcr ltrrrlly ol pcriury lhnl I xnl untlcr provrsiorr ol Chapler 9 (crn)nnen( inE wilh Sc(lx)n 7{XI)) ()l l)rvisr)n J <br />ol thc Bu\irx'\( irtrl Prr)lcs\i(ms Crxlc. iuil nlv i\ nr lirll torcc rnll ('lli'(l <br />l-iecnsc f lnss:Z:\/ <br />issucd (Scc. .](197. Civ. ('.). <br />l,cildcr's Nanlc: <br />Lcnd.r'\ Addrcss: _ <br />APPLICANT DI;CLARATION <br />I lurhv rllilnr undcr ltnahy r)l lErjury oDc ol thc li)lk)wurtr (!!'chrnl ioD\: <br />l)r.nrrlition P(rnrits-AskLsto( N(nilieati(n Fcrlcral Rcguhtions ( l illc.lll. I'xr1(') <br />_Rcqun'c(l l,ctlcr ol Notllicrtrn) <br />_l ecnrly lhnl lhc lc(lcrrl rcgulrtions rcpruding asltstos rtrnoYalirc ilril x[)pli(xhlc n) lhi\ proic(1. <br />ordirrrntcs rnrt Slrl( Lrw( t.hlrnlr t() hurl(lln!rcprcsdililivcs ol thl\ Cily and (inrnty lo cnler uF)n lh(- <br />xlx)v. nk nlr,I.rl Inr)1tr'd! lln rr(l)crlr)n <br />Appli(rnl or Agent <br />l'(.rilrileo nxilrc (priill <br />xn(l hcrcby <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 />Framinq <br />lnsulation/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 />Enoineer Final Reporf <br />BooC Toge Cerlif ., I lt Ir 4 <br />{dAtMttDr{flr l9ht ,44)oA 044t0(74),r/ /,la <br />FINAL J '4',[4?rW l\Ao{W 4 <br />Certificate of Occupancy I <br />Notes, Remarks, Etc <br />I)rlo