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BUILDING. INSPECTOR RECOHD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNIX BUILDER DIiLCARATION
<br />I hcrcby rfiiln undcr Fnally of pcrjury lhll I afl cxcnDl ltnn lhc Contracron LilTnr Llw lor lhc lolhwiry Eav,n (scc7oll5
<br />Busn$s md P0r'csnn, C{xtc): Any Cit! .r Cou.ry $hi.h E{trncs a pcirnir h .oh{fl.r. ,hs, inrpr.vc, d.nml,sh or rrsn nn,
<br />ntocfurc. Fiorlo irs ksuancc,,lm rcqtrtcs rhcapplicanr lnrsuch |E nit b ulc r si8ncd st0tenrcnr th tuorsh.hliccn$d plru r
<br />to Ihc pnvnioN ol dc Conlra.u s I-i.cn!.\:l Ltrw (Ch+rcr 9- Com6.n in! wirh sc.rion 7{)0o ol Divilim I olthc Busnr* and
<br />Profc$ions Cdc ) or lhat hcorsh. is crc,n/ thcrctomnnd rhc harh for lhc rllcScd cxcmplion AnyviolatioflorScdionT0ll.5 hy rny
<br />.mli.a.r r(tr r Fmil subjccri lhc lpolicanlto acivilpcn0lryolfr, flDEttun rivc hundred dollan {$50O)
<br />-1.
<br />as owncrol rh. toFny. or my.mployccs *irh wagc\ a\ rlrt $h.onrpcnsrnrn. *ill do rh. wtrk *kl rh. iG-rE i\ tror
<br />inrcnicd or ofirrcd ror qle lsa 70.1;l, Busincs rnd l}olisi.trs Cqlc, I hc Conrracrn s l-icensc tjw docs nor apply b o o*ncr of
<br />rhc Impcny wlr t4ilds or ihprurrs rh.m.. *d who do.s su.h wd* hnn\.ltor hrnclfor rhrough his or hrown cmployccs.
<br />providcd lh:lt such iDprolsmnsmnori cnd.doronard r(n sdlc.lf, howcw. rh. buildir8 or nnpmw.Enl n bt wilhin.rc rr
<br />llcoflulelion. rlr Owncr Buildcr wll]harc lnc hrdcn.irrcvin8 rhar h. or sh. dil ft, build or iqrovc $c pmFy h! lhc puqnc ol'
<br />I. N .wtr.r .f rhc pml*nr. !n eiclusivcly rof,rBcrina sirh liccnscd conhcron t, o.{rucr rh. preFr (S.c 7()44. Bulinc\s
<br />arn hDfssi.nCodc TheCo.k!.roasLiccnsctjudocsnorrpflyroanowncrof!tup.i!yNhobuildsorinrF.vcslhcrcon-
<br />and who.ontDcr\fqsrchpmjcckwnhaContaclq(nlccnscdpursDanrbrhcConkrt,\Liftn\eLaw).
<br />l rD,cxctr'tr tr l.rSccrn .B &l'('lorrhisr.r{tr,
<br />I!)ntr.[&r:rQ[IfENSAIoN
<br />Irl:ga.BduoN
<br />I h.rhy rrlirmun,l.r p.nilly.lp.rjuryom.lrhc lollowirE dccloarnnrs:
<br />-lh.!c
<br />md p ill ruirhin a Ccdili.0rc oi Co.snr losclrltrsurc ior workcs .on{'ctrs,'i,nr. as pmvidd lor hyScdionl70ool Ihc
<br />tnhor Co&- nn thc p.rlorromc olthc qolk lo lhich Ihc pcrnril ir hsucd
<br />I hlvc and tillnuinkin workcrs compcnsulion n$u.!ncc- rs Equncd bySNlim:l7lx)oirhc LnhorCodc. turhc !.rfonumc dt
<br />rfu *ork lorwhichrhi\ pcmir is issuct Mywo,krs con{cn\alion insu,anccc,tricr mdpolicynumhcr rc:
<br />Ftndk- Lem .J
<br />o *[$)\q
<br />I ccnilirhrr itrrh. p.rfonrun.cofrhc work for whichrhisp.nnir h ssucd- I shrllnor c.'doyinypc6oo irary manmr
<br />s rs ro bccom subFcl to lhc *orkcrs mmpcnsrlion ldws of Colilbarid. and l8rcc lh ill should bc.om suhtc.l rolhe
<br />workcis' conDcn\at,on pmvhio.\ .f Sdrbn l?00 ol rhc tlhn Cr c, I shall. fonhqirh .omply Rirh rho* provisions
<br />WARNING I' lurc ro ccur. workcis .onrN.sarion ov.idgc s unlawtul. and shrll subF.r r..mtlorr lo cnnrinll FMltts and
<br />civil li.cs ut h otrc hund.cd thou\dnd dollds ($100.001)).
<br />'h
<br />rddniotr ro rhc.o ol.oDr|c.salon. damScs as tmvilcd hr rhc
<br />Ssrion.1076 olrhc tjto c-odc, inrc.cs rnd.uormy s f.cs3l(v J.t-.."'7.1-C)
<br />LlllNlriD1!.ryI8 (rQB
<br />DI!TTBtrI]9!
<br />Ihcrcbyaliirnrunddpemllyorp.rju.yth0lIamli.cn(nundcrpmvniotrofChrtcr9(comnrncnrSwirhS.c]iotr7Oo0)ofDivisionl
<br />of rh. Busft\s and Pmf.ssions C.dc. dld nry li.cn* i\ in fxll brcc ,rld .ff r
<br />nno5r"-'qLl!71 tfr .*,,-*, F"r tPrrt [@ir"y tn"P
<br />.CONiI&,]CIONIENDIXGIIiEdCI
<br />I hcrcby afrtm uDrcr pcnally of pcrjury lhar rherc t a.on(ruclion hndin8 a-qcncy fitr rhc pcrti,rnBnce olrhc N.,k tn,hhh rhi\ Fr il is
<br />tsued (Ss. 1097. Civ C.r.
<br />lcc ilyrh rht fcdcral rc8!lllion\ rc8udtrg r\bcsro\ rcrmval rrc nol{pplicnhlc bihi\ nn+cr
<br />l.rnrfy rhnrl lr( rrd rh( rlplicrri{Dr {r!crhar rhctrh)vc inhnnrnnr i\ corc.r lrgrek'complrqirhrllcirr rnJ Corirl
<br />ordiDam.\ rid Si c tf,w\r.UriiB n! cone cri(,n. md hcrcbyadrhori2r(prr\. nin3ofihtCnyandCounryk,.nr.ruB,n
<br />rhove m.nrioncd Imp.ny ior inlp.dion
<br />2etian 9+lAw
<br />*", g?LElE
<br />Set Backs
<br />FormsiSteel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Il4asonry
<br />T-Bar I 'lt*fir t '*u4b-/z
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL a *r./t*'---rlo.o 16t-
<br />Certilicate of Occupancy
<br />Not es, Remarks, Etc
<br />t
<br />I
<br />Pool Fence
<br />A.IILICANLIECIASAIION
<br />I hotr,, ifinn undcr pcnqllyotpcrjury om ofrhe lolloNin8 d(lflorions:
<br />Dcmliion Pc nils-Asheslos Notlic,lion Fcncml RcEUlntions ('Iillc 40. Pd6)
<br />Rcquircd krrcr oa Nolilistion
<br />I
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