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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNIiR BUILDER DET-('ARATION <br />I hscby aflin unds paalr, of !.dulv rhar I d dofl nod ihc (ontacrors' License h{ for th. followitrs rcMn {ss.7011.5 <br />Butin6s ard Prof6sion Cod€): ny City or counry $nicn rcqutc a pennil lo consrruci. 31t6. inrpro$, dsnolish or €pat dv <br />sdcru., plior ro ils issudc., also requiE fi€ applicet for such pcnnn ro fiL a sisncd slaleddl rh.r h. or sh€ b lrcoFd p6udr <br />to rhc pmvkios of th€ Cont.crois Licetrs.d Low (Chzpid q, CoDndcin! whn Sdion 7000 or Division :l ollh. trusin.ss md <br />PrcfNio.s Codc) or lhd hc or shc b .xdnpl lh6efion md rh. b*is lot rhc .lleBcd €rmplion. Any vnnarion ol S€clion 701 I 5 bv uv <br />aDplicanrrorapolnnsublctsth.applicantloacililpc.ahyoanornDrethdfivchundr.!dollaB($500) <br />l. s owns'ollheDrop€ny. or dy.6ployc wilh {aa6 d rher $lc.o,np.Btlioa. Mll& Ih. sor* dd lhe sru.lG is nol <br />into(H or o0cr€d lor elc (sd.ro44. Busind and hordiod Cod.: Tnc aonrrador s Licd. tnw &6 nor apply to m o\n6 ol <br />rh€ p.!F.ny *ho buildr or i,rprer6 th6n, dd *ho doc slch \ork hids.lf or b*lf or <br />'hroqh <br />Ih or h{ ow! cdplov.6. <br />proLidqj rhar such inFlvffirse d i.nod.d 6r ollaql forsle.I( ho\r6, th. buildin! o. imlro\qncnl b $ld within on€ ra <br />of.o,npldion, rh€(nrrr Build. will h e lhe h,tm ohovins lhll lr or sh. did nol hlild or inprov. dc pmFly lor lhc purlDr ol <br />-1.6o\id <br />oalhc propdly. mqclusiv.ly.onkaciin8 wnh lic.6.n codndo* tr codru.l lte rmjd (sc. 70'1!, a8itrd <br />d hofsion Cod.: I h. Co.rrscloa s L iccosc La*' do6 .or apply ro 3n orvns or propdy wlD builds ot impiov6 rhdsa. <br />and who contacls fo. such prcjcds *nh a codBdo(r licosed pu6ua rorh. Conlracrdrs Lic.N tjw) <br />-l <br />dn ex.m unds Saln,n-. tr &PC lorrhisrcMn <br />.EO.StrEsSllOMfEXlArqB <br />DEC}AAAIIA! <br />I h6.b, .rrm unds DdEhy of pojury o.. of rh. aollo*ins dEls.liom: <br />-l <br />hav. and $ill nainlain E C6rili.ar. ofcoB6t to Sclf-lasure for work.c comP.nsalon,6 ,ro!id.d lor bv Sdio.1700 oflh. <br />t,abor Codq aor thc pdfomuc. of t& *od( for wtich rhe pmnil is issucd <br />Zfii-v. aid will maiilain wdk.G' conp.tuarion iBur.ncc. 6 requncd 6y sdr io. 1700 oalhc lab.r ('od€. lor the psfonnan.. ol <br />rh. sork loi $hi.h lhis p.flnil is iseed My wor*d! co'npasarion insur4< cmid and policy nu6bd dc: <br />,.t "r^,^*' 4(o'1/i lfZ -o)-o I ,,0r,.'/, <br />I ceniryrhal io lhc polonBrc oarhc work lor which rhislErmn is issued.l shallnot srplov.nvpeMn inan, nmncr <br />e as ro beoi. srbjd b lhc Nlrkn comp.nsar ion l.ws o f ( alilomd dd ,!rce rhat il I should bdo '. subid to lhc <br />*ork6 cohp.nsalion psv$io6oISdion 1700oalte Llbor Code,I sbrll.fodh\eilh compty wirh rhosProvisioN <br />\rAiNlNG: Failurc r. -curc worteE comp.Gdion .ovchsc is unbwful. dd sh0ll slbjd o fllloyer r. si,niul FBhi6 dd <br />r, .f. h( trtltual rh.u\xnd d.llars rS 0lr.l11)(r). ir <br />rf <br />D&CllEAIlA! <br />, hmb, afirm und6 p€nally ol pdjory lhal I m lic.us.d undd provirion of Chapt6 9 (connmcin8 rvilh Scclion 7000) oa Division l <br />of rhc Busi.6 ed PofsioG Cod( a.d h, licG is in lull lbtce dd .rar. <br />,B9rBa6- <br />o,r. lt l,s-f /g <br />collllllcuoN.L[NDllclc[lcr <br />I h6.by a,Im undd Ffl.lry oi pgjury lhal lhcc is . connrudion lcnding aldcy aor lh€ psromDnc. of thc wort ror rvhlch rhis lEmil it <br />isu.d (Ss 1097. Crv c.) <br />APPLIC NT DFCI ARA'I'ION <br />I hodry drian u.d6 Fflalty of p€rjury on. of lhc followi4 dclarations: <br />Ilmolnio. Pcrmts-kb61os Nolification F.d€rtl Regul.tions (1 itl. 40. Pan6) <br />_R.quiEd lrtd oaNotifi cdnr! <br />I c.rlituthal rhe L{6d(AularioN rctddina Gb6tos ronoval t. nor.pplrabletolh's o.rccr <br />y'lditorhd <br />I fiav. rud rh (arerhar rhc at[J!. i'rlonn.a I r!'ero (on,fly Nih ill(' <br />ro htrildi',c connn'd n 3 {lhflc[\ <br />poq lnr iBpetion p04ns l r(-//C,o <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB FIoor <br />Subf loor/VenUl nsulation <br />Roof Sheathing <br />Shear Wall l\ <br />Framing !r-\L(IC <br />lnsulation/Energy <br />Drywall V%t) <br />Ext./lnt. Lath <br />Brown Coat <br />lt/asonry <br />Pool Fence <br />T-Bar tq tg <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL l'zt-11 k.uLtL <br />Certificate of Occupancy \J <br />Notes, Remarks, Etc <br />-+ <br /><,td,<{rD <br />/.-..\ <br />c*. -lAtC -TNq zo <br />L.ndd': \am( <br />- <br />lenJ.' ! ddN <br />- <br />lT=E=rr <br />I <br />I,