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BUILDING- INSPECTOR HECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUII.DER DELCARATrcN
<br />I hcrhy affirm lndcr !.dhy or Frjury rhd I m cxcmpr riom rh. c(, rn.ros LiccDsc Lrw for lhc li'llowinS rca.on ( s .70,1 1 5
<br />Busincsq r Prorcsskr Codc) An, Ciry or coutrly whi.h Equncs a tcirnir ro .on(dcl. llrer. improw. dc'mlish or rcp0n ary
<br />strucrure. prior ro ns n\uonc., rko rcqutcs rhc uplliclnl for suc,r perni h nba silmd ndcmnr th.l h.ot shc k licencd pusuur
<br />r. rhc rovi\ion\ .rrtr Conrm.ror's Ltcnkd Liw (Ch,tr.r 9, Conmcmins *irh Seclion 70(n of Divkion I oalh. Busircl\ and
<br />Pmicsbns Codc)orlhrr hcotshc h crcmrl rhcrcfro'n d th. brsis a.r lhcllLscdcrchprion AnyviolnrionolScclion?0.11.5l'ylny
<br />aprlicanr ior a Irrnir u$Jcck rhc rpllics i{, acirilFnalryolD.r 'B,crhn nv. hundrcndolrs (S50o).
<br />l. a\ o*nfi or rhc pk,lrdy. or nry cnltnolccs wnh w.gcs N rhcrr (,k com|Enn( i(,n. * ill do r $or* ard rrE(Murc is nor
<br />irlcnncd or orlercd lnr slc (5(.71).14. Buircs and Prcli$i{trF (adc:'l hc C{,ntr.ttr i l-i.cnsc Lrq doc\ nolanply ro an osrcrot
<br />rhcptuFn, wh. hu'ldsor nwo\rs rh.cnr Nld qhodessn.h$.* hir{cll orhcrscliorlhrolghnn or hcr own cmploy.cr.
<br />prolidcd rh i such i'na'ovc'rnh m noi inrc hdorofi.rcd li,r srl. lll hoscvcr. rhc hoildin8 or imlflMnrnr issokl*irhinonc )sr
<br />o, n'.lplerirn. rhc Owm, BuiLlcr will haw rl.. hunhn ol ,n)vin8 rhr h. or shc dil frn iaild or i'rqhvc rtt potdy tor rh. Durln* of
<br />l. rsowicr.l rhcFrncny, ancr.lu\lr.lr.onrn.rin8 trirh li$tr\cd .onti.ton h cofl{n(r rhc pnjccr (Ss 7044, Buenc$
<br />urd F\na$iotr C.dc 'I hc c(r ructtr s L.iccnsc t,!wdoe\ nol lpplyt, ano*ncr of!tupc y who builds.r inrlrove\ rh.tcon-
<br />and who contr.r\ ftr su.h Eojc.rs snh 0 Grnn.lon s) li.rtr*d Nnu l b rhc o)nrr{ckr's l,iccn\c lrw)
<br />I uncxchpr utrdcr Sccln)
<br />W(}RKI]R\' C(}IIIPFNSATION
<br />DEIIAXAII!}N
<br />I h.,9b' Jll n urdc' r{mlrJ ol l.qury ^m ^l'r l{ lcllntr rns JNlnrar
<br />'nn\
<br />-l hr\ c rhl u
<br />'ll nud m a ccd 'rf,Jrc ol con{or r. sclt.l nsur. io workcn uom|].nsrlion- ar lflrlid.d for by sc.r6n l?00 oi thc
<br />l-atu Codc. n, rh. IcrlonEn.c of rh. work ln whih rh. pdn r L\ issuLal
<br />lh,vc ond *illm,ihtrin rortcrl conD.nsoli()n iNursncc. as rcquircd hySccrion lTmorrhc libor codc. for rhc pcrfonuncc o,
<br />thc Norkforwhichlhn Fnnit is hwl. My{ortcN co r!.nsarion insurlnce cari.r,rd Flicy nuf,h.r -cl
<br />(-^<. ). ,L*; c^nt
<br />2/rAL 91q34l tr F.,pt", ct.l/oy'a.1
<br />-l
<br />ccnilyrhll ir lhc rcrlornEncc olrtE sork ntr shich Ihi\ pcnrii i\ i\{rd, I shrll n.r cn{loy 0ny lcnon in any manEr
<br />\.r\r,bccorsxhrc.rk,rh.uo&ef.onD.n\arii,rI0w\orCrtrr(xnir.indrsrccrhrrillsholldh.comsubjtcrrorh.
<br />workcis' .onlt)cn\dion [ovisiotrs of Sccrion ]r([ oi rh. l] rr Cnd.- I sn ll. lonh$irh 6hply wirh rlr,* f,viin !.
<br />WARNIN(; failure io wrrc so.k.^ .omp.nsrrnrn covcrilc ii unhwrul. nnd shall suhjct .n cmfk,ycr io cimin,l I. rlri.\ 0 d
<br />cilil finc\ upt)onchui r.d rhou{! d dollrn (S100.flXr. ir lildiri(nr k,rhccorl oa c.mpcnsrrion, drme.\ $ providcd l thc
<br />Sccno.1076 olrhc bbor Cod.. inrcrcq md oary s ltcs.(r"" ot/st/a
<br />utENuiDrQrllt tlltallllLiBiIIIO!
<br />I h.rcby afllnn u d$ lrnarty of,xrjury rhd I aD lircns{ utrdcr provnio. ol Cnlpb 9 {.onnNncirg Bilh Sel iotr 7({D) of Division :l
<br />or rhc Bu\ifts 0trd Piorcsions Codc. a my licctrsc is in tull lorcc mdcrtccr
<br />(r"*
<br />\,'._
<br />"r*,,
<br />(,,)a /6 )ra/yy0nrqi
<br />CONIIAIJCIIONIENDING.{GEXCI
<br />I hc(h, nmrnr und.r Fn0lryorpcriury rh,l rhcr. is 0.onnrucr nhtrdiql8cncylorrh.pdrornun..olrhcqortfotwhichrhislcmirh
<br />nsucd lss :1097.Civ. C )
<br />aftucAll"lt&cLaaAflaN
<br />I hr.lry alfinn unrrcr Fnah, or Frjury orc or lhc nrhwin! dehrd ionsl
<br />Dcmlition Pcnnih Asbcsros Nolificarion Fedcrl Rcsularionr (Tirh 40, P,n6)
<br />-Rcquncd
<br />Lellcr of Mlifi caion
<br />I c.nify thrr rhc f.dcinlrcsulrrioDs rc8ddirg nsti.{ns rc n,v!l(r. mI rlplicrhlc t,rhi\ n',Ir.r.
<br />-l
<br />ccnililh l halc rc l rhn lptltrrt r aJrl { crhrrrbcrtx'ld nrrohurnr l\(oEccr.l0E erocoarPly*irhallcnyand Q)unry
<br />ordin.k_cs md Sllrc L{rsrldins ro blildin8 con(dcri{nr. u h$chr"Mrhtrizcrcprcsctrlorivc\oflhhCn,lndCoudyto.nlc.utonlh.
<br />0tnvc mrioncd !'oFnyn)r insFction puqxxcs
<br />,\fl,li.ml .r Aronl Sia altrrr
<br />\"-r,* *.",u"r,T-si J t.-1,,,"ar "",., a&t/q
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsu lation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />IVlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />/n\
<br />FINAL l0-lo-)1 k-\ttlul
<br />Certiticate of Occu nc
<br />Notes, Remarks, Etc
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<br />Lcnds s Nam'
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