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. BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG COMMENTS OWNI:R BUILDf,R DEL( ARATION v, \./
<br />I nrcby alftrto lndd pmalr, ol trjury that I an .r.hB from rn. Conlrado6 Licd* rl* lor ih. folloqinB ras. (s( 70,1 L5
<br />Busin6s and Proa6sio, Codcl Any Cir, or Counly *hich requn6 a p.tril ro .odtu.!, 61td, inlprole dmolish or rcpai M,
<br />snlclu.. Inor lo its i!sud.c. al$ Gq .s rh. appli.er for such Fflnit lo file a sisn€d slalcoc lhn h. or sh. i! li.@d p6udt
<br />lo ln€ I,ovisios or rh. Co.ta<toas Li..neJ Law (chaflc 9. Commcncins rvilt Setion ?000 or Division ll oalh. a$in.s ed
<br />PrclLsionsCod.)orlharhcorsh.iscxemprlhacliodedrhebaJislorrh.rll.g.d.xdplion. Any violationolScnbn 7031.5 by any
<br />.pplicadforap@ntuhj*rsrh.,p!li.mrloa.ivilpcnlyoanolmor.thaofivchuldr.ddollr.($500)
<br />I. 6 ovn€. oi Ihc prolEny. or my eftplorB sith sas6 6 lhet $lc $mtsMrion. Nill do I h. *'orli dd !h. sh&ruc s mr
<br />inrdd.d or oil€red lor slc (sa.7044. B6in6 dd P6 fBic Codc Thc Contdor's Licdsc I !w do6 not appl, ro d osnd oa
<br />rh. p6pdy {ho b{ilds or nnprore th@q ud trho do6 such $A hnns.lror hdselfor rhrouah his o! hd owo.mployc6,
<br />p(vdcd rh,l .u.h inprovorsts e mt idod.d or olT6.n for slc I L ho*.vs, lh. tuildins or imprclmm is sld lithitr onc }!a
<br />ofco,npkion, th. Ownd Dlildo lill have lh. h!!d oiFovins lhd h. or shc did mt toild or nrprovc lh. preldly lor tc purpor ol
<br />-l.
<br />6 ownd or th. Forsry, m.rclusivcl, co.lradins vnn licsqlconl6to6lo co({o.lrh. Fojd (Sd 7044. B6'ns
<br />Md PiolNion Cod.: Tt.Contretors Lic.ns.l,!* do6 not applyro moqnd otpmp€ny who builds o. inprclcs lh(@.,
<br />and vno .onr@ts aor such projds with o ContEclo(, licdsd puE@l lo th. Comr.ctoas Licffi L3w)
<br />I m.rdng md6 Sarion
<br />Drre Owner:
<br />IIoBKESLCAIIIIISATION
<br />PECI.dIAIIAN
<br />I ho cby ammr undr p.,aly oapdury on. ol ft. lollovinr d(hrdio6:
<br />I nave dd * ill naidrain a Cdincarc of CoGa lo S.lal Nure lor wolkm compsrelion. a Folde! for byselionlT00 oflne
<br />Labr Code ior lhe p6ton. ccoflhc$ort Iir whi.h rhc pnnir is isucd
<br />Iha\.6ndsill,nainrai.$o 6 compcnsalion insumnce 6 requn.d by S<lion 1700 of $. Labor Codc, aor th€ Flom ccol
<br />Iho worl lor wnich rhis p6nn i! is.d. M, wor t6 comp{slion i6uroc. cei6 and F.li.y nu,rbs d€
<br />,*., .3aq oa,lcalqlL
<br />ori","-"r*,' 1lll2?g
<br />6^0
<br />.,,,",,- t[r(zozo
<br />I ccnirylhat inlht Flod c.of$c*orl{lorshichlhisp6milisissu.d,Ishallnotonployanyp.Gonin,nymannd
<br />$ srcbe.on subjd lo th. \ori6'ompss.lion lflssotcalitonra. ed ae@ rhd ial sholld bdom. subjccl lo llE
<br />wod(6 comp.Mlion prorisioN oascclion l?00 ofthc Lab.r Cod.l slEll fonhvhn.omply s'ith lhos povisioB.
<br />I,VARNING: kilure ro sr(c workc6' co6p.@ii.n.ovcmg.
<br />.rvrl linc\ up ro une hunil'd rhoJs,l d,lld rtr1u0.000'. in
<br />S€dtun 1076 ofrhe Lahor Codc. hrc6( ed ar$m.y's acs.
<br />drnalB 6 pro\ided lor Ihe
<br />I heeb, amnn u.d6 pd.lry of pGjury thar I am li
<br />ol the Busiis dd Pof6si.tu Code, ed 'nyli.
<br />illchrpra 9 {comd.ing wilh Sclion 7000) olDivaion l
<br />,"",q48y'7 con,r..,or
<br />I hd€by alfir m undr p.n!lr, o f pdjury rhal lfid. is a
<br />hsu.d (S.c. 1097. Ci!. C ).
<br />aracy ft)r rhc pdfonnec. ofthcvork lor which rhis p<mii is
<br />AIIUC ILDICLTAAIIOI
<br />I hscby rli.n unds pe.alry ol pdjury on. ofrh. followins deckalio.s
<br />DcnDlii.n Ps'nireAsb6tos Norificarion F.n6al R.sul.rions (Titl. 40, Pan6)
<br />R€qun.d L.lr€r of Norincar0n
<br />I .d ilt rhd rhs acddrl r.gularioN resedins 6tEro! rdoval d. n6r 0pplicablc ro tlis prcjEt
<br />]r.*'ry rhsr I lEVe rqd rh6 applicalion dd srarerl'.r I asrero..dpl, Nnh all ( iry.nJ ( omry
<br />oidi.ancB ind staic L.ssrclalins lo iv6 ollhis Cn, ed Countyto mtq ulon the
<br />abovc n@lbndl piopdy lor iBp(bn
<br />ApDltrnl or is.nl Sit .rurr ,,'., t fZ44
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenUl nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing lzl*lt1 DA*s -*87
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL l'4tdta -It';nl.l.fr '^L2b)
<br />Certificate of Occupancy I U
<br />Notes, Remarks, Etcq.
<br />t
<br />Pe.mirccnrmc(p.iil): L
<br />rrlq
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