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BUILDING. INSPECTOR RECORD <br />(nln.rBuild.r D€clrraiion <br />I h.rcby afitrm under p.nalty ofpcr|urv llEr I inr.x€rpl lorn rh. Contrcr66 l-'c.ns e llw lor lhe follaw'.! r$son (s.c r0ll.5 <br />dnd Pror4sion ('od.) Any Cily or Coum, which r.quira a pcmn roconslrucl. ilrcr. inprov.. dcmolish or r.nat.ny srrudur.. pnor I trr <br />issu.nc.. also r.qnir6th.appli.rnr ror ru.h pdmrtlo 6l.a sisncd sl.t.m.nl Ihsr h.orsh. is lic. .d pr6@nl lolh.rrolisroN olrhc <br />ConrBcrois t.,c.ns.d I au (Ch.pr.r 9, Comm.nc'ns wnh Ser'on 7000 ofD'vrrn l oarhs Rus'n6s and Proa6rons ( ode) or rltrl h. or <br />sn. N cx.'npl rhcEiom indlh. b6h lor rh. all.*.d .ranprion Any viol(ion orS.clion 70.11 5 by.ny 0pplicflnt ror. pemn srbj.cBrh. <br />amli..nt ro i civil p.nihy ornor hor. rhan fiv. hundrcd dollars (150o). <br />l-s o$n.rolthe propcriy. o! nry .n{loyc6 wirh \r4* rs rh.n rok cdmpensalion. silldo lhcwork and rhc yrudurc L nor inr.id.d <br />orolT.redfo'srl.(567o4.r,r}!nn6sandProi.snonsCode'lh€ContactoisL'c.ns.La*doc\norspplyioitrownsofr[eprop.dy <br />sho builds o nrnrov6 th.r.on, iod whodo.s such Lvork lrimscltor h.6.lfor rhrourh his or h.. ow..dpl6y..s. prolil.d rh3r slch <br />impror.m.nrs ar. nor inr.nd.d oro[.r.d rorsl..ll h.$.v.r. rhe builditrs or improrcm.nr is soldwirhin on. r..r orcompldbn. rh. <br />O*'n.rBuild.r $illhavc ln. ntrrd.n olprovin! lhd h..r shc not build or improv. for lh. purFs. ofsal.). <br />I. aso$oqollh.lropcny,.mcrch,sivclyconlractin8 airh li..nscd.ont.(ro(ro..nnn'cl rhc poj.d ( Sc. ?044. !]usin6s aM <br />ItoLssionCod. Th. Contrdoas l,'.ens. h* do6 nor.pply lo a. owna olplopenv *ho bu'lds or inrprov6 rhcron. ind who <br />c.ntrcblor strch proj(8 wnh a Contrcto(, lic.ns.d pu6u.nr rothe(onradois l-rcens.lrw ) <br />I tun cr.nrpr triJ.r S.crion <br />lIORXERS ('OMPENSATION DECL RATION <br />I h.r.b] .mnn und.r p.iah) orrcrjuryon orrhc nnhwitrs declararions: <br />I ha(..nd sillflrinr.i. aC.ninc|r.orcoB.nr ro sclrlnsu'. ror worksr con,pcnsar'on. as prolided ior 6y Serrci r700 oarrE <br />tibor ( od.. forrhc p.rfonMn.. ofrh. qor& f.r wfiich rh. Frmil is issu.d <br />I h.ve.nd willnrrnrari wo,lere conDenstbn <br />'nsuranc., <br />as requtr.d bv S.ction ]T0OolrhcLjhor (ode. aorrhe performnccoflh. <br />worl lo, phich ih6 pennn 6 Bsu.d My *ork.r'.omPeneron 'nstrranc.crtrEr and policy numb6 ar.: <br />*",,"r*r.a.. JJU6,('lhis sdion nccd nor b. co,npl.r.d i <br />l55Lk $uc ncnn t nr {rr htrndred d.llrs lSl00l or lcss) <br />I..n,rylhar in rh. p€,fomaoc.oath.work forwhich rhisp.rnrn is issu.d,l <br />h.omo subr.cr ro th. mrl€r ' comp.nsr 6n liwiolC.|lorn,., rnd i!r& rh.r ,rl should h.cotr'€ rtbr6r h rh. so,ldr <br />nl' " h,h.*179M( <br /><-+ <br />("mp.m,rrcn p'o\Llron.ag((!oj 17OO ofrhc Lib.r Cod. <br />",, a/A!5 n,*-, <br />WARNIN(; frilu'e ro srtrrcworkcG conpeN.ron colc *4u1. and shrlln'bl.cr rn efrpl6y.r ro.rihinal p.mhi.s and civil <br />fin.s up to oa. hudr.d lhousond doll06 (1100.0{X)).in iddirion <br />rh. llhoraod., 'nr.'csr a.d il(orncy s aces <br />or.omp..sarb., drfr.gd ar pr.vd.d f.r rhc Sccn.n 3076 ol <br />IIIEISEDTOXTBAITOAIDECTA&IrIAI <br />I hcr.by amr und.!p.nalryorp.rjL'ry rh,r I a6 k.ns.d uod.rpro\ki.nolChaptcrI(co,nrn.ncins qil[ S..iion 7000)oiDivision l or <br />rh. ausin.is ind PrcI6sio6C6dc. and my lrc.nsc n in aulllorcc r.d clld <br />Or., ( <br />D}L.D2:1p'|,-D7\-!^3 a1 <br />j---.t!._-> <br />I ncrcbyaffirnr nnd.rpcniltyoll.r|ur]_ rhat rh.r. is a conitucrion g.n.y f{tr rh. p.rft,manc. oflh. sork lor*hi.h this pcrnril t <br />is Ed (S.c 3O97.Civ. C ) <br />AATIICANISOECIAAAI,]OT <br />I).holihon Pcn ik Ash.rtos Notncalnn led.ral Rc3ulalions(rnb40. fd 6) <br />R.qut€d l..rrs olNolifi carion <br />I.ediry rh,r rh. r.d.ralr*ularionr r.c'rdins sh.sros rmolal arc nor applicablc ro rhis plojc.r <br />I..niry rrrr I hav. r.ad rhis,pplicarnnandstat.rhar th.abor. inform ion tcorecr l a!r..rocomDlr sirhallairyand aounrJ, <br />irn.s ofrhis(ity ind (-ounryto c.rour..lh. <br />/i-./.* y.l 4. Lt <br />SITE-WORK DATE ID/SIG,COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUlnsul. <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsu lation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL r'/24/tL -14-rl )w4a) <br />Certificate of Occupancy U\I u_---. <br />Notes, Remarks, Etc <br />M \WP5l\Pem I'lnspeclion Forms\Building l.speclon Record doc 03.31.06 <br />LrJ <br />s/z/ //S-rf/7