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BUILDING- INSPECTOH RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS oWNER BUIIJ)!]R DELCARATION
<br />I hcrcb, aliir undcr !.n0lry of pcrlury rhar I am cxcmfr Imrn rhc Conlraclois l-ten\c lj*,orlhc fdbwin8 rNr (SL7r):ll5
<br />lJurinc$ ard Profcssn,n Cndc,r An, Cily or Counly *hi.h requircs i pcmir ro condtucr, rhcr, inltrUvc. dcnrl,sh or rcp{tr'!try
<br />\rrucrurc- ri.r r{i ih issuanc.. also r.quircs rhc applicor fttr \uch Frfrir b li}c n silncd dmcmtrr thlt hc or shc n liccnsd pu Mnt
<br />ro lhc povhions olllE Conrractais t-icc.*d ljw (Chlprcr 9. Conrmcncin8 *iih Scdn TUXI of Division 3 oI lhc lru\'nc$ ani
<br />Pn,fcssn)hs C.dc) .r rhli hc or sh. is cxcmpr rh.rcfro nnd rhc brsn t rh. rllcgcd cxcnDrion Any vn,Urionofsccrn,nT0.ll5 hy rny
<br />aptlmnl lnr dpciinil nrblcdsrhc afflicont to rcivilpcnrltyoln.r mordhin five hun.lrcdd.llm ($50o)
<br />_1. n\ osner of rhc pRrFny. or m,.oDlorces wirh ssg$ rhct $k conilcn\aln . will do llf work u lhc(Mturchtrol
<br />inrcndcd or offcrcd Lr slc ( Se 7044, ausincss rnd Ptufc*i.ns Colc: l hc Contmcroi r Li.cnsc Lxw docs nor lpply t, ai oukr ot
<br />lhc pn'Irny who huilils or inDrov$ rllcmn. rxl wtr &f,s \u.h rorl hi'nrcllor hc^clror ihn,uSh hi! oi hcr own.mploycc\.
<br />[ovnbd rh.t srch im!rctsEtrrs aE tror mrcdcd or offcrcd for {h ll nowcvs. rhc boikiins o' itr{mw,m issldwirhin'ftFr
<br />orronlphrio.. rhc Owrr BuiUcr *ill hav. rh. budcn ufrbvine rh,r tr o. shc dil mt toitl or inpr'lc fic pmpcny lor rh. llrFl?of
<br />I.$o*nfiolrhcptupcdy.rn.klusiv.ly.ontncrina*irhli..n\c'lcont.cttrsrolon{ructrh.p!()icr(Sall}rl.Bd\inr\\
<br />and PNlc$k'n Codc: The Conrrlctois Liccnsc Lrs d@\ nor lprly ro anowncr.rpi{rpcdt qh. buildr or improvcs rhcrco..
<br />nnd who coftach f.r ruch !ft,l.ck wirh rC.Drr.rtr(t) li.c.\cd puNa ro rhc Conrr0.rnfs l,iccns lr*)
<br />I rNcxcn|, u ldcr sc.r
<br />t rr. ()wr:
<br />DECI,AIAIIO!
<br />I hftby aratrm undcr pcMlty or p.riury orc or$. followin8 d(larlrbns:
<br />I hovc dJld will minrain r Ccniiicrt.orCon$nl ro sclf.lnsur. for *ork.tr ompensotion. !s pmviledforbyS.crhn l7morrh.
<br />Lnlrtr C.d.. aor ih. p.rformnc. of rhc ert for *hkh rhc ldmir is hsucd.
<br />-l
<br />navc atrd will roinhin workcs' comoensarion insuronce. !s rcqutcd hy Sftl bn :1700 or lhc kbo! Codc, lor lh. FrfonMncc of
<br />rhc work tur which rhisErn is issucd My nln|EtrrI(ioniNtrrsncccrricrrtolInlli.y unrh.rdc:
<br />l..nilyrhrr inrhc t^-rlnnrtrm,n rhc *1rl lar $hrh rhi\ ncnn'r tr ^\ucd.l nrlltrfr (.r." *.- t-,,*-",
<br />v, as b b.om subjccl lo Ihc workcn comp.nsation laws ol Culilnni!, and aBm. rhar ifl \horld t .ont subi.tr ro IIE
<br />*.rkc6'conrpcnsatiotrF)visionsofSccrionlT0OofrhcltrrEtrOic.l\lDll.lirnhwiih
<br />r ,n.nDbrrr ro diminol Fn.lrics lndIYARNING: Failurc ro sc.urc s.tkol co,nNnsahotr ..r..ngc is unh ul.
<br />to onc hundrc{l lhousrtrd dollars (SllD.u})), ir ndilil
<br />Sc.ri 1076of r Ltrlu (i{.. irrcrc{ r altoncy s
<br />DrtLttstl!!\
<br />I hcEhyrlfirn undcr rculrlol plrjury rhar I $r lic.n{d undcr pr,!rsn, ol Ch.J)ld 9 (conrnEmiq *ih Sccrion 70ff)) ol Di\nn,n:l
<br />L(6)-
<br />CONSIf,!!:UONIEIDAGACENq
<br />I hcrby ,itrn und.r lEn,lr, or pcrjury rhar lhcE n a .onsdcrbn hnding ascncy for rhc pcrfooEncc of rh. wrk for whi:h this [{ml n
<br />i\s!.nlscc :1097. Civ C )
<br />APIIICANI.DECLAEAIION
<br />I tEEt y ltfim ondcr Fnnh y or perjury oft or rh. rulluwins d.cli In nsl
<br />Dcmnilion PcirniIs-Asbc(os Norilicrrion Fcd€nl Rc3lluri.ns (Tirlc.r0. fd6)
<br />Rcquncd t.rlcr or Noli,icllioo
<br />l.cdifyrhar rh. fcdcnl rc.cularions rcBardiry 0\tr{o( rcnniv!l arc nol rtplicnhlc &, rhnlroiccr
<br />_l ccniryrhar I hrvc rc rhh lppltrrionr darc rhar rhc xh,ru infttriuridr is
<br />ordiDinccs md Srlic ttrws rcUrins k,huildin8
<br />;::::::,Tz
<br />r,.,',r.*,r l,*,'',,,.,1' q",,.
<br />,": l(ar/rs
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framino
<br />lnsulalion/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar lr
<br />Handicap Req.A
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil t
<br />-\.)//r sa9 .a4cv
<br />Certifi cate ol Occupancy
<br />Notes, Remarks, Etp
<br />7
<br />FINAL
<br />Co,lc. rd 'nl licctr\. \ n lulllnr.c xn'lrlfcd
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