|
BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS O\YNER AUILODR DELCARATION
<br />I hcrcby ,fliim undcr p.ialry of pcrjury rh.r I am .xcnpr li.nr rhc Contrcror' Li.cnsc Lnq for lhc followin8 rcasn (s.r 70.11 5
<br />Ausincs trnd Pror'cssion Codc): An, Cily o, C.utriy shi.h rcquncs a ,cflnit lo .onsrrucr. rlrcr. impn,vc. crctu,lirh .r nl)an invr
<br />dtucrurc. prhrro irs issuucc, aho rcqutcs rhc arpliclnt lor such pcrnrir lo nb a si8ncd {arcftm rhr rr.i she is liccnsd pusua
<br />ro rhc !rulisions ol th. Conr&rols Li.cnscd Law (Ch,prcr 9, conhc.cnr8 with Scclion ,O0o of Divhn,n 3 or rhc B!\inc$ 8nd
<br />Pnr'essbnsGrde) orlhat hc orshc iscrc'npl rhc.ciro,nandlncbasn lnr lhcrlhBcdercnlPrn,n Any!n,hin,iorsccr6trr01l.5by.ny
<br />ippli.rtrr Lr r p.rmir subJ..B lhc rmlicant r..civilNnrlryofn.r 'mrcrhrn ilc hu rcddollan($5m).
<br />l.asowftrorrh.poprny..r.ryc,nplorccsurhwd!.!r\rh.irv,lcortctrsdnnr.r'illdolhcwork lh.slnluci\ior
<br />inicndl{ or ofcrcd li,r ulc ( Sc 70.,4, Au\iresr rnd Proicsln'ns Oic: l hc Cotrrr.ntr \ l-ic.ns. h* do.s i.r olrply to an osrcr of
<br />ihc pDtEny wh. hlilds or ir{'rors rlEarn- ot who des such qirk himscllor hcFcllo' rhrouCh his or hu oqncnPbyccl.
<br />pn,vidcd rhri suh i'npmrc'tunh d n i'nc.&J or.flm{ f{r srlc ll howrr.r. rft hu il'lir8 or inpovcnE hFkl*irhin, 'rtuolcoq)lcrir[ Ilr Ownc. Buildc. will hrrc Ih. budcn ol pruvm8 drr hc or shc did ml huild or i,n!.orc thc Dmpcd! tn lh. pu4rs of
<br />-1.
<br />usowncrolrhc pmrcny. !!nciclusivcltcotrrrucrinE wirh liccnsql conlrrt,n t' co {tu.r rhc prorc.r (s(. ?(!14. Uusncss
<br />,ni ProfL\\bn C,xt.: Thc Conkdor's Liccns.lrw do.s nor apply k, d.wn$ olp.otEny wh(' brilds.r improrc\ rh€rcon.
<br />an{l who conlmcrs aor such pojdr *irh a Conrracto(9 liccna{ purulnr ro rhe Conract t Li...se tje)
<br />-l
<br />am cxcmo urncr Srction-. B. & P C lor lhh ,cav,n
<br />Dalq Ontrr:
<br />WORKERS' COMPENS'dTI.)N
<br />IIECI,IAA.IION
<br />I h€rcby ufinmundcr pcnalry ot prr$ry otrc oflnc {ollo*iry dNlararions:
<br />IhrtrudwillrunnrirrCcnih.rrcofConscnrroScllli\urcldwork..onfrtrroon..\prolidcdloriySslion.lT(Xrofrhc
<br />lihtrCodc.I{nlhcpcrio.omnccof rhcsorkforwhichlhcFnnil i\krucd
<br />I h,vc and willma,niain workcrs comPcnsitiotr insuran.c. rs rcqulrcd hyScdion:1700 ofrhc tjbor Codc.ld rhc p.rr.rmm.c or
<br />lhe work forwhi.hrhn pemil is tsLn. Myworkcs co',p.-.slnr insuramc coflicr rn p.licynumbcrec,
<br />-!
<br />ccnit thar in rhc llcriornEncc oflhe wort lor *hich lht pcrnril ir i\rucd. I shrll nor cntloy any Frson i. any ranNr
<br />$ ,r k' trroft s!l,]cd ro rhc worl$L.bhpcni n,n Irwt of Crlifdnir. md +rc thd ilI should hccom sutlrl rd rh.
<br />work&J Lunp.nsdion ptuvisions of scclion 17fi) ol rh. Ljtxrr Gdc, I shlll. fonhwith .onDly q irh thosc pmvirn,n\
<br />lvARNINer Frilurc lo aurc wortcr snlFn\dion s,vcrlsc is ulasful, and \halr subF.r n .mpbls ro si'ninal lInohist,nd
<br />civil fif c\ up ro oN l,tr0drcl rhou\rtrJ doll r\ rll(Xr.(Xx)). i'r ll(i
<br />(itrlc. i, c'o{ r artn f,r'\ fus
<br />J ,)
<br />DECLAAAIIOX
<br />I hcrbyrlfirnr und.r p.n.lryoftE jurr rhot I an licctrscd utrdq rmvish. ol Chlpts 9(conftncins lirh s..!ion 700OJ ofoiviton l
<br />or rhc Busimssand Prufcsions Codc, md my liccnsc k ir full lorce md cfltcl
<br />C!}NSAICIONIENDIIiCJI;ENCI
<br />I h.rubyrmnnundcr Fnahyorpcruryrln rhnc k , orn rudion hM,n8 aBcrcy for lhc pcrloilErcc ol rhc sorr ror wh{h th's ,Ennil is
<br />nsucd (Scc.3097, Civ C.)
<br />Afftlc tifD[clA.8.&r.l0N
<br />Ilf,dry nnnundcrI[n hr.l !.rjurt onc ol rhc lnlb* ii8 d( lntur n,\l
<br />D.nrlirn l,cnnils A\bc{o\ Noriri.l tn, FcJcrrl RcEtrhriu rlil.,t0- I'rn6)
<br />R.qunc(l lrlrcrol Norillcrrinr
<br />I ccniry'ha h.lcdcmlrcBUIdions qudinB osbcnos rcmv.l ffc nor applicablc b rhis pn+cr
<br />-lccnityrhd
<br />I hNc reM lhhrprliciliotrtqlslllerhr lhu trh,rc intunnlli,m n cotucr lasrNr,.omPltwirhillCnyandaotrnry
<br />ordinln.csrnd Shrc Lawr rchri.sro huildiiscor(rucriotr. {lhcrchylurhori2crcpr.\.nrdivc\orrhnCry,ndCounryrocnrc!u$,nrh.
<br />lbvc mnrt'ncd poprnyfor iDstatiotr purFscs.
<br />Alplicanl or AA€trt SiloaluR ^$/<lK
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Venti lnsulation
<br />Roof Sheathinq l.lo-/9-L ,*-,b41 ?
<br />Shear Wall
<br />Framing
<br />lnsu lation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Itilasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />En gineer Final Report
<br />Flood Zone Certif .
<br />FINAL r/p,/h rNfs(
<br />Certif icate of Occupancy
<br />NoI es, Remarks, Elc.
<br />Set Backs
<br />,rr", 1 /3 i?'
<br /><Ur JrzrnL+
<br />T------=
<br />I
|