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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNI'R BIJILDIiR DEI,(ARATION <br />I hdeb, aflifln und6 paah, of p€rjury lhd I m ei.mpr ftoo lh. Conlructo6 Licens. tiw lor the follouinB ll&n (s4 7011 5 <br />Busin6s dd Proisioo Cod.): Ant Cny or (ounly whi.h r.\ton6 a p€ ii lo conslrucl. alt6. nnprolc. ddbolish r rePn , <br />noc'd., Fior ro its irsroce. also r.qut6 llr applicmt lor such p.mn lo fiL a sisn d sldmat rh{ h. or sh€ b licm.d p6u&t <br />to rhc prcvisiod .r rhc Conlr.clore Li€.ns.d tnN (Ch.ptr 9. CoDncncins wilh S<rion 70\10 ol Division I oalhe Susin6s d <br />P@a.sions ( odc) or nlat h. or she is €rcrpl th6e6on sd lh€ bsG tor rh. allcscd .xonFion Ary rioltrlion ofScclnrn ?0ll.t fry a.y <br />aDlic.nl aor a p€mil subjcB the applic ttoacivilpcnaltyornolnDrclh&fivehundrcddoll&s(t500) <br />- <br />L as o"nd o f rhe p(!cny, or m, .mployG snh waBB 6 nEt $le comp..slio!, Nill &, $c \t tnd ihc stn(tue is ml <br />intddcd or ofiscd lor el. (56 70.14. Busins ud Prcf6io6 Code T1. contraclols l-iccN. Lo* do6 nol a!rl, ro m osrr o f <br />tbcDbndty *ho hilds or imDro\6fi€@n. ard *lF d(E such srrt hi s.lf or h6daor rhmqh his or hd otr n.nploy6, <br />Fmvid.d lhal su.h intmlmnis m nor idaxk or ofided lor sl.. If. how*q, rh€ bqildins oi inprovmdt is vnd within o.. )qt <br />olcompl€lion. lhe o1m6 BuiU6 will havc lhc bd&n oatrorins $a b. or shc dil mt hrild or nnp.ort $e Fopdy lor rh. putPos ol <br />-l,6oMoordc <br />p6po1r. m .rc lus iv.ly .o ntrct if,B wnh lictrd conlradoB lo co.srtud rh. r.jd lsa 7044. Rlms <br />and Boftssion Code: Thc Conr&roi. Licds€ L3* do6 nor apply to u ownd o f prop.ny wno builds or mpre!6 0(md. <br />aDd who conrmds for such Aojat wilh aCo.r6oro(s) lic@d pursmr to thcComracrois Lictue L.w). <br />Iancxcm underSerion-. a & P.C.lorrhis reason. <br />llaliEErra[uEls figx <br />DECLATAIIO! <br />I ncreby affim undcr p.nalry ol pdlury odc o f rh. followin! d(laralions: <br />-l <br />halc d will ma,nhin a Cctin.ar. ofconst ro sclf-lBur. aor srk.rs comp.nsarion, d rrovidol for by Serion l?00 ot lhc <br />l-abor Code. Ior thc pslomancc oilh€ rork lor whi.h rh. dmn is isu.d <br />,lhaveand{illmainrainwork.6comp.sarioninsorance,6r.qun.nbysdlioi:lT00ofrh.LabotCode,forlfi.tEfonndceol <br />$. \ork nrr sbich rhi pmir is is€d. My sorkfi comFcalion imurdc€ ceid dd Flic! nu,nbd r. <br />I c.niiy rhai inthcpdfo,nranceofthctro fo! {hich this pmnir t issu.n.l shall nor mploy flny pqvrn in anymdnd <br />$ as to h.coN. subjer ro rhc wo&6' comp€Mrion l.*s oacalilomia. lnd asrce llEl il I .kruld b..o'n subi4t to lhc <br />vort6' conpcGarb. povisioB oasBion i 700 of rhc L.bor cone I shall. fontvnh o Vly rirh rhos Provisions. <br />\n'aRN|NC: rialuc Io *u. $o&m' comp.Nali.n colm8. is onLNaul. ed shall subjdr d mplold ro aiminal poani6 d <br />.r1l fin.s up k, one hundred rhousmJ dollas ($100 ion lo rhe cosl olco,np.Mrion. d,naB6 6 provid.d tor rhe <br />cod.. im6nt Md atro!rey s 16 <br />!lI!L!!l:lUL <br />I hcEby amm undo paally o apgjury thal I m licds€d trnds pmvision olChafls 9 (.ontmmcin* trnh S.dion 7000) ofDivisbn l <br />of lhc aBiner dd Pna6ioro Cod.. d my licft. is in full forc. od cfter. <br />Ql) \7,,"",."",". v. Aor.ritr{crrAt <br />gr![lBullralr[dllNc-dcrill] <br />I h€rcby amrm unds pen.lly ol pqjury nl.l lhqc is a conslrullio. knding a8ocy lor th€ pdaomuc€ oflhc trorl for $hi.h rhis Fmil is <br />i.sudl(sa 1097. ci! a ). <br />AEI,TCANLDECIABAIIQ! <br />I hoah, ailnn undd pa.liy of pgjury onc ol the folloNins ddlEations <br />Denolirion Pmne^sb6rN Norifi.rrio. ltdsal R.sulalions {'I iil€ 40. Pan6) <br />Rcqutcd t4lle ol Notincdion <br />-l <br />cdiq nlal th. lcdsal resuhrn ds e!trdi.C ab6ros t molal e. flor.pplicablc lo th6 projEr <br />I cdilrlhd Iha!.readrhisflpplicationsdsrarelharrheat{\e iofomarn,n G.oadr IaEerocomply\rilhallCnyandcou.r, <br />ordi.ancs and srdc la$ rclarins to buildina cons1ructtun, od hscbyaurhoEeqnc$lariv6 oafiis Cny and Counly ro dld ltxin rh. <br />aborc nE(ioned prepedy l'or itupdr <br />rpDlir!tr1 o' ,\s.nr sisnrrur..rr\a)r/ <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/Vent/l nsu lation l. <br />Roof Sheathing ,/'zt /ll -HA <br />Shear Wall <br />Framing <br />ln s u lation/Energ y <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Ir,4asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL lz-7-6 4<1)itz'7 <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />6 <br />LenJeir ^dd6 <br />- <br />Pern ile nrnF (pnnr ): E