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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OTVNER I}U II,I)I]R I)ELCARATION <br />I hcrchy rllirm lndcr pcnrlly of pcrjury that I rm c\cnrpl lirnr lhc (itririclor{' I.iccn\c l.aw li}r lhc ti)llowing rca(on (Scc.7(l.ll.5 <br />Rusincss anJ Prolcrsrn (ixlc): Any City or oilnly which rcquircs { lrrmil lo cr[slnr(|. xllcr. inrprovc. dcnxrlish or npair any <br />lo lhc fll)visirnrs ol tlN (i)nlraclor's l,iccnscil [-iw (Chrplcr 9. Crrmnrcncing wilh Scclx)n 7UX) ol Division ,l r)f lhr' Bu(inc(s rnd <br />Prolcsst)ns(ir'lc)orrhatht'orsht'isexempllhcrcliotrl{ndlhchasislirrlhcallcgcdc\clrptur. AnyviolationofScctrrnT0-ll.5hyany <br />lpplicnntli)rrlErnrirsilhjcctsthc rpplicanlk)acivilp('naltyolnotBn'cthxnl'iv!-hundrcrldollarstiSs(x)). <br />_1. as ()wncr ()l thc prr)|riy. or my cnrployccs wilh wrgc\ r{ lhL'rr sr)lc coDrpcncxli(xl. will(L) lhc wolk rnd lhc stn(lurc is rn)l <br />srlc). <br />I. as owncr ol thc frultrly. anl c\clusively eontrrcting wilh lccnrcd contrrclors k) con\lrucl llE pr).ic(l (Scc. 7(]44. Busurcss <br />and PnrlbssirnCrilc: l'hcC()ntrick)r'sI-iccoscl,aw(locsilolrpplyloxnowncrol'proltrlvwhobuildsorinlprovcslhcr(nl. <br />tld wh() conlrrclsli)rsuchnfi)jcciswilhaOrnrrclrnl\)liccnsdlpursuanlk)thcConlrrcklr'\l-lccn\('l.nw). <br />I anr cxcrnol urilcr Sc(lx)rr . Il- & P.C. lbr lhis rcas(nr. <br />lV()RKI'RS' ('()NTPENSATIoN <br />t)ti( t,ARAl toN <br />I hcrcby nli irnr unrjcr l)cnrllv ol pcr iur v ()nc of I hc li)ll()will[ rlcclirrl iou\: <br />_l havc uxl will mintah a Ccrtillcatc of Conscnt lr Scllllnsurr lilr workcrs'conlt--nsalion. rs [ovilcd ti)r hy ScclirD 37(X) ol lhc <br />tilnr C(xlc. li)r thc perli)rnuncc of thc work for which lhc l^..^rnlil t( i\sucd. <br />thc work lor whrch thi\ lrrnlil ir isrutrl. My workcrs ((,trrlRn\rtlon inrurancc ernirr anrl lxrlicy nunrhrr rrc: <br />Policy Numhcr: Expilcs: <br />_l ccnily thrr i[ rhc Frlbrnrancc ol thc work li)r whie h lhis l^-rnril is i\sucd. I shrll not cnrploy nny pcrson in any iunncr <br />so as k) tx.conE suhjc(l to thc workers'compcnsati()D hws ()l ('ililinrur. rnd acrce lhil il l shoukl k.errrru subjcct t) the <br />work(.rs'conll{n\rlir)trlrovisi(rlso,Sccli()n.17(Xlr)lthcl-ahr(ixlc.lsMll.litrlhwilh(r,nrplywilhlhoscprovisir)ns. <br />IYARNIN(i: l:xrhrr. t) \.(uc workcr( conrf^-D\rlxnr is unlawlitl. and shall suhi'ct rn k) crimiDal lr'nrllic\ xnd <br />eivrl linc( up k) onc hiln(lrcil thousrnrl dollrrs t1l ur adtlition k) lhc c()sl ol'i{ pr)\'xlili li)r lhe <br />Scction lhc iril.rcst and <br />I hcrchy rllilDl un,l('r l)etrrlly()i pcriury thrl rilr L(cD\cd ultrlcr pfirvi\i(nl t) l(r)trrnen( in! wilh Scclftr 70(X)) ol l)ivi\x)n I <br />r)l lhL. Bu\tncs\ ilrxl llolessiorrs (1xlc. rnrl nrv l,cc[\e r\ ir lull l(n(c nrxl !-lli'cl <br />I <br />Liccnse <br />I hcrchy altirfir nndcr frnrlty ol pcrjury lhd <br />issucd (Scc. .l(197, Civ. (:.). <br />isa ion lcrrtlirrr apc'ncv lirr lltr'p.rlinnlnrR'c t)l lhc work li)r whrch llr\ |rtmil i\ <br />l,cndcr's Nrtrr. <br />[-cntlt'r's Adrlrcss: <br />APPLICAN'T DECLARATION <br />I r+rthy all-unr unrlcr pnrlly ol I--rjury r)nc ol lh!' Ii)lli)wtrrg dcclarrlions: <br />Dcnr)lilion Pcrmit\-AslEslos Nolilieali([ Fcd(-rrl Rclulilion\ ( I illc 40. Pdi6) <br />Rcquircd l-cllcr ol N(ililicrli(nr <br />-l <br />cfll ily lhxl lhc ltrl.r al rrSlrhlirms rcgxtdirr i\h.slo\ k-rnilvil trL' not nlpli( thl(' to lhis l)r1)ic(l <br />I ccn rcr(l lhi\i()n iln{l \tnlc lhxl the xh)yc inli)rillrlir)n l\I iwrec lo ron)l)lv wilh rll ( itv rrxi (i)lrrlv <br />rIlinxI(c\l-rw\ rclnlinS <br />Applicanl <br />I'rnnilc( <br />lhn( I <br />l'rr <br />rn(l h.r(-hy xulh(JrizL'r)l thi\ <br />:;T',;i"'"'""''.,'" <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence 1-L.1- ( I J)e 9'4 *(g) <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL o-/f- /q ,/)r{rh G?> <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />1