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BUILDING- INSPECTOR BECORD
<br />SITE-WOBK DATE troFro.COMMENTS OWNER BUILDER DEI-CAR TION
<br />I hcrcby alfi n nndcr !.nah, of pcdury thit I fln cxcnu rmnr lhc Conlador' Liccn\e Law lor rhc i.lb*inr Esi,n (scc 7031 5
<br />Bu\nr$ aln Proacsion Codc) Atry Ciry or Counl, shich r.qutcs ! pcrnir b .lnnflcr. ,lrcr. nntov.. d.rmlhh or rc,,n ry
<br />nd.r!rc. prtn ro irs issucncc, dlso.cqun.{ rhr q'plicunr ll,r \uchlcnrir ro filc, signcd stalcnrtrr lhar trorshc n licens puru.nl
<br />lo lhc pruvisnnrr ofrhc Conkmtois Liccnscd tiN (Ch,U.r 9. Comnr.ncing wilh Scclio. 7UD of Dirnioo I of rhc B!\in.\\ lnd
<br />P.olc$i.ns Codc)orth.l hco,shc kcrcnrfl lhcrcirom0nd thc hnsh forthcllle8cncxcmplion. Anyviolaliooo(Stcri{n'70ll5byany
<br />{plicnm forapedn suhjccrs rhc rppli.rnr ro acivilpcnahyolnor nDR rhnn fiv. hrnnr.d dollrs(5500).
<br />l.r\ owmroflhcpmlEny-ormvr pk)rtu Nirh *r!e\ n\ rhcir q,[ m lpd \ar i,u. will do rhd woik xtrd rlf {mtrrc is nor
<br />idc Ld oro,Tcrcd tur srlc (So 7(}4-1. Btrsnc$ dM PrufcsidN Codc l l* Cotrtr.rois Licc.sc l-uw docs n.l ,pply b rn o*mr of
<br />rh.pmp(ny Nho builds or inlpn,E\ itlron. a.d +ho dcssch$lt hinNclforhcrrltorrhntuEhhi\ or hcr otrn c Dl,)yccq
<br />|rovirlcd rlfu su(h nntR)trft . tu. tu i,n.ndcJ or ollun] li)r sk ll, h$tvcr. rh huiLlrA nr n\rx)rc.rnr i\ v,ld wirhr one ].nr
<br />ofcoivkiir rhc O*mr auil]d $illMh rlf t{rdci ofF)ving rl hr u' \hc .r htrild or i'nprnvd ilr tn'ni} to. rh. puqr,{.f
<br />I rDcrcmpr u .r Sc.lio
<br />Orn€.
<br />]1l)8trr&i:!l)}lfrNsa-ll!)x
<br />DllcL/rXIUll!
<br />I hcrcbyafllrnuMdrcn,lryoin rjuryomofrhciollowm8 ..!eriions:
<br />{p[lhdcin]s'lltru h Jccnrfic cnlcor\cnrr.srlrlnsurcft,wDrkcs.onrpcnsnlion.N prclnbd lorbySccrion:lTlnofrhe
<br />ljhr Adc. n, rhc pcrfonuncc olrh. wolk ror *hich rh. prrmir n iisocd.
<br />-lh0vc
<br />0nd willmrinl0in workc^ compcnslrion insurinc...s rcquncd hy Sccrion l7(xlofrtc t:bor Codc. ror rht lElforruncc of
<br />rhcw.rklb.whichrhnpeflnitisissucdMy*orkcrrcomFnsalionin\uEncc.!tricr,"dpolicynun'bfidc
<br />c,"i",, . Do Guxtn
<br />C)to / zr, /r tT:- T --0
<br />I c.niatrh,r inrhc l).raormM..ofihc work foi shi.hrhis pcnrn it ir\u.{.1shrll nor cn{loynny!.rbtr in lnymlnmr
<br />vr stobctunE suhr.l lo rhc!o sl snlPcrsrnr hws ol Cnlil'a,ni!. !fr| l8rcc lld ir I sh,uld hco f, subjcct ro ttE
<br />workcF qnnpctr\uliotr povnn)nsolS.clion:l?otloirhc ljkr C(xlc.l shrll. rodhRirh conll'ly wirh rhosc Pmvisions.
<br />WARNIN(; Fsilurc !i, s.uc wltrkcis ..nrrcnsdioi ..v.rr8c il utrirwtul. nnd shlll subj(r 0n cmplorr l{' oidind n MIrt\ 3id
<br />civil fincs ut r(, on. hu.drcd rh.uund doll&s (1I(D,fiX)). in addiri.n to rlr co( o, compenerion. darugc\ as polidcd for rh.
<br />."Jftr?:iiz"
<br />ni.r.n xnJ rn,trk! ( 1..\Z-44.
<br />DECLAAAIION
<br />I hcrcby aflnnr uDdcr pcnalryolrciury th0l I rm liccn*d nnd.r pn,vision ofCh{0ler 9(co'nmrcins *iri Sarion ?filo) orDivhbn -l
<br />oa rhc Busincs Md Pnfc<ionsCod.. dd nyliccn\c h in lull nncc ard crat.r
<br />1
<br />lrfrr: t A 4 Iq ".,*"*o(
<br />coNs't Rt ( lt()N LIiNI)tN(: Act,tNcY
<br />I hcrby.fllimxnd$ Fnahy.lr.rju.yth0I dcrc is r.un(rucri,n Lndir8 r8cncy liir lhc perlinnocc olrhc work (tr whi.h rhn p&nrir h
<br />i*u.d rscc 1097. Civ C.r
<br />AITLICANLDICIABA]IO!
<br />I hcdry oltlm undq pcnaily oipcrjury onc ol rhc folloqinG dcclahrions:
<br />Drmoliri( Pfimirs Ash.sos Noriflc bn Fcdc(l Rcgula(io r (Tnlc,10. Pdr6)
<br />RcquiEd trttcr ol Nolnicitnnr
<br />_l c.dilyrhrrrh.liturrlrlrlxt otr\..grni',! r\h.no\ r.nnMlx'. iorrtitl lJl. ri rlr ( t).ofrr
<br />F*:*lrl1'llr;rcrd lhtrppli.rrion I salc rh|l rhc rtt)vc nrlorrotFn isconcct.l:l8re roco'nply*irh nllCny Lnd C.u.iy
<br />ws Nl,ring to huildi.S con(rudion.,.d hcrchynuthorizc rcrcsnrarives ofrhn Ciry and Coonry k,,fi{.+ry
<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 />lnsulationi Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Mason ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />E ngineer Final Beport
<br />Flood Zone Certif.
<br />FINAL
<br />Certif icate of Occupancy
<br />Notes, Remarks, Etc
<br />Subf loor/VenVl nsulation
<br />Brown Coat
<br />-1.
<br />$ owmr of rhc lhpcny. 0m cxclusivcly coMr.hn8 snh li.cDs.d .onrrlcroi{ lo con(rucr rh. pmFr (Scc ?oi-1, au\itu ,r
<br />md lt,ltssirn Codc Thc G,ntactr's Li.cr{ l-aq docs nor rpply b m os d.r or |)()r.dy sh. bnilds or nnp(rc\ lhrrc.0.
<br />n wlD coflrdcrs fd such pmFlls wirh! O'nt0cb(s) liccnscd Nnuad t,,lhc(-orrrscroi\ Liccosc bw).
<br />-il, :;;:: irP-?_ .,-.---
<br />pcmi,ecnone,prin,,:x P$-rU--rea-v
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