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BUILDING. INSPECTOR RECORD <br />OWNDR B!ILDER DELCARATION <br />I hseby amnn rndq poalt! olpdjuryrn l mcrdnpl 6oar lhe Conlraclo6 Licflsc Law forlhc lollosin3 ra.on (S€.70115 <br />h6in6s and Pnlixsion Code) Any Cily or Counry Bhich rcqun6 a pfl1il ro coGrrud, ahd, nnpro\., danolich or rcplt any <br />s'tu.iurq prior to its hsuan... rl$ requn6 rh. appli.anr lor ruch ,imn to fiI. a si8n.d salmd lh8l h. or she b licd*d puEuant <br />lo lhe prcvisions of lhe Contracto.s l,icdscd l,aLv (ChaDre. 9. Comnrc.cins Nirh S*rion 7000 of Divtsion I oalhc B$in s ed <br />Ptufdrio.s Cod.)orrh.r h.orshc is qcmfl rhdl6o6 dd rh. haiis for &c all.scd erdprion. An, \iol.tionoascclion 70ll 5 by.ny <br />appli.ani for a pnnil subj(Brh. appli.anr ro a.ivilpenalrtol'nor nor. rhan livc hundred dolles l$500). <br />l, ar osnftnlrh. propcny, or nryc.Dloy6 sirh *as6 ar thc'r sl.( pderion, \ill do lh. $ o.l dd fi. $nxru. b ml <br />intmd.d or otrded for elc (5(.70.,14, RBin6 and PmiNions (nd. Thc (-onradois Lic.ns LaN do6 nol arply ro u o\r( ol <br />rh. poF.rlr- Nho bnildr or inpro\ 6 rh-Bn, ,nd who do6 such slrk hims.ll or hd*lf oi tlroush hir oi h6 os n cnplorce. <br />pror idrd r har such i'npdvmnrs e. ton i.rod.d or oftdd flr slc lf. ho\ 6 s. rhe lnildint or mlmvmr is $ld rhin"nc)€ <br />ofcodplcrirn. rhc O\rrs Buildq vill har. rh. hrdo ollro\ing rhar h€ o' sn. did nor hild or ihptu\ e rh. popdy lor lhc pd,F* of <br />6 o{ner ofrh. p6pdr!. m cr.lusir.ly comr,.rinu trirh li.Nd.oiIrrco6ro co..ltuct rh. projd (Sd 70J4.lrEins <br />and hof6i.n cod. TneCookocrors Licen* Lawdo6 n r appb ro oNnero|prop.nyvho builds or mpod rhstun. <br />and trh{ conrBcG for such trojccl. \r,rh a Conlnch(s) licmcd puGund ro rh.conka.rdis t-icds.l^v) <br />lm erenrpl ond€. SErion 3. & P.c. rofs <br />,X_tsLttlLg_ <br />I n€rcby a,IrB undo p.n.lly o t pdju, y oo. of lh. folloNin! ddl&ariom <br />IhaveddNillmnr3ina(€dincsteofConsdlroSclf-lnsur.lorsorlqs compc.srio!.6 p.ovid€! for bySdion 17(I0 oalhc <br />libor Code. tor rh. ElcnndLc.trl.. \o* l.rtr'hrch rh. pmn is isucd <br />I hav. and eillnainraio *orkdr' corrpcBalhn iNurrnc., s requned hy S(rion :l?00 oarhc Labor ( od., aor $c pdtomhncc ol <br />lh. sort for shich rhis pdnil is Ls.d. My *orl6e ..mpssrio. ialrMce cmi6 ed policy nu'nb6 r€ <br />Poli.lNtrrnbd: Expt€s:t/'(4t.a,b rt'^r <br />'n <br />rl'. rornt.inc. otrh. $ork for whrch this p6mir is issuc{L I shall nol oploy any p.Mn in any ndnd <br />$ ai ro bc.ohc subjrtl lo rhc No&6 .ompc.erion la*s otc.liaoBia dd ,eft rhd ia l should b..o,n subid lo lh. <br />\0116 &npoerio. pftiri.ioEolserion l?00 ofrhc Lrhor Code l !h.ll. fodhs'ilh comply Rith rlmppmvisioN <br />\IVARNINC: Failur€ to ss. \ork6' comp.trdion cov.h8. is unlnqtul. and shall subjrl e flploys l. fininal FDhi6 and <br />.ivil lires up ro one hundred lholsd dollaE (t100.000). ir flddirio cosr or.o'n!.Nrio.. dmald d prorid.d a.r rh. <br />Sd'on 1076 orth.l,ahtrCodc, inlfd aod arlomq-s rE <br />"lrt I t a <br />I hmby amrnr unds p6ahr ol psjury lhat I an licdsdi ondd provision olcfiaplgI ( <br />of rh. Busin6s dd ProacioN cod.. d ny li..nse is in tull tunc and .tld. <br />sih Sarion 7000r.f1)'\ isi.n <br />Li..nsc Numbc: _ <br />(0liltrlcflalliNultcd;.ENc! <br />I n€rcby amm undd penalt, olp.rjurythot lh6. is a coniructiotr lsdlnA o-!.ncy for In€ pqlonnmce oftheryork lir $tich lhis pomir is <br />issucd lsc. l0'r7. ( n (') <br />AIIIICAI[DECLAAAIIQ! <br />I lE€ty afim und€r p.n0lty olpcrj'try one olrne lollo\cinr dc.lar.lions: <br />D.rnoliriotr Pcanils-Asbrsos Notincation l,edsrl Rcrulalions 0 nL 40. Pan6) <br />R.qxircd Lexd of Norincolion <br />l.dily rhd rhc fcnddr+ul.rio6 rqddinr 6h.s(os rdno\ al oc tror lpplicable to this pDj..l. <br />.dilvrld I h.\€ rsd rhis aprlic ion $.t.rha! rlE aiFv€ inlomration is corsr. lasreto coDpl, \vilh allCiryand counry <br />ordinancB d Slarc Ij\ s rclotin! to tui <br />abov. nrc io..d popdy tu impaxion <br />6 ofthis Ciryed Counryro.nrd trpon rlr <br />SITE-WORK DATE tD/stG.COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenUl nsulation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulationi Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Itila son ry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report .! <br />Flood Zone Certif <br />I <br />FINAL rl 1 q-\iiv> ) <br />Certificate of Occupancy lr : <br />Notes, Remarks, Etc <br />to1lu <br />1 4o o