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BUILDING- INSPECTOR RECORD <br />OWNI'R BUILDER DELCARATION <br />I hd.by . mn. undq D.n.lry of rf,riury rhar I ex€lnDt frem rh. ConrcloB Liccnse tiw for the foud in! r@n lse 70l l t <br />Bsin6s dd Plohsion Cod.) n, Ciry or Counr, $hich r.rtunB a p.flil to conslrucl. 6116, nnprolc, dsnolGn or q'.n t <br />srtu.ru., prior ro irs isu ce. also requnB the applicst for such pcr. ro 6L a siSn n nard. rh.t he o! sh. G licoscd p6uda <br />ro rh. provisiaro or EConlracloisLic.nscdti*(Ch.Ocrq,CommcncingrvnhS<tioi7000ofDivisionIoflh.Busia*Md' <br />Prof.sionsCod.lorlh.lhco.sh€is€xempllhs€iiomandthebsisfotthcrll€g.dcxonption.Anyriolaxonofs*lio.?0ll5byiny <br />applicanl for.p6nit subj(crh. applica ro a civil p.oaly ol nol noic llE fiv. hurdrc! doutrs (rt00) <br />-1, <br />d o\ ner oarhc rndFnr. or m, mplotG with trag6 s rh€t $lc co,np6slion. *iu do Oe $ oA dd $. (nrc1r is nol <br />intdded or ora.J lor sle (56.?0.1.1. Busins and ttofesions Codq Tn. aontDclois Lic.Dsc l-as do6 nol apDly t. d oMo of <br />rh. prolJt] s'ho hrild! or imt,o!6 lh@n. md who do6 tuch \ort hims.lfor h€6cllo, rtrcush bk or hd om enplor..6. <br />provid.d th.r sucfi ituprovdndis ft nor i dd.d or ollGdi ftrr ht I I howdq. rc brildiry or i'lpmvq@l is sld wirhin on. )s <br />ofomplcrion. rhc OMd aLiBc will h,!e rh€ htrd6 oaForins d h. or sh. dil rct boild or ingrov. rh. ptuFry lor rhc putDos of <br />-1.sowtrcrofrn.,xopdr,uncxclusivclycorraclin-q*irhlicosedco <br />tac$6 to cotrltucl ll1. ptojccl (SE 7044. R6in6s <br />and Eoaesbn Codc Th. conracbfs Licmr l,aw do6 nor ,prly ro o oMo o aprop.n! sho builds or inprolci lhddn. <br />and rho coirrels aorsuchrrojds witb r Co.lrado(s) licm.d puBuanl lo lhcConrBclttr s l-icsc bw) <br />_l dnexmpr md6 sNrion . B. & P.C. fo,lh6 r6on. <br />D.te: OBn€r <br />laaliESrto!!8Etl4llo! <br />DECIdBAIOB <br />I hd.bt amrn und€r r..ah, ol pgjury ooe ol the lollo\ins d(lIaxo6: <br />I halc md $ill ,n.inrrin a Cdilicat€ oI C.6ar ro Sclf-lmurc for *ork.B' com!.nsarion, s Fovid.d for by Sdioo I700 ofln. <br />Labor Codq aor thc p6fomdc. of lhe work tor wnich the pmil is Gued <br />I havc and willflaini.in workert colrpeNalion insurance. er reqund bys(tionlT00oflhc l,abor Codc.lor rh. gctonnecc ot <br />the $ork for which lhis pmil i5 <br />,)- <br />.odp.tudio. iGurdrc€ cei6 ud Dolicy nun,bo &e <br />cr\3Lt <br />-l.diiaylhar <br />in rh. p&fonnmcc ofthc worl tor shich rhis pdmit is iisucd. I shall.or mploy any p€6otr in any mend <br />$ 6 lo b6onE subjd to th. sorldJ co'npmaridn lass orctliiomia, ed air e rtar il I should b..ome subj<l to rh. <br />*0116 compoerion ptuvisioG olsd io. 1700 of thc Lator code I shall. lolhtr irh co'ndy wnh rhok povisions. <br />WARNINC: railurc ro s@. *o'k6 .ompdelon covdBe is trnla*'tuI- ad shall subj(r mrlo)s ro nirniMl l@lri6 4d <br />civil lin6 u! kr onc huodr.d rhdusMd dollds (9100.0c{). ni addinrn ro t <br />\ <br />or!.tr,tJ.isdioi. dtuna86 6 providql ror lh. <br />Sdion 1076olrhc lrtnrCode.intda ddrnomN s ,.K <br />i- [q- t'a t<r- <br />IICINSID.CANI3ACIOA <br />DEC!AAA]()! <br />I h@6y .rm undB !.nalr, oi pdjury thal I dn licosd unds provisioi o f Chaprd g (.o,nnEcins with S.dion 7000) ol Diviion l <br />ol rhc Busins and Prol6iotu Codq and m, li.€N is i. axll aorc od cfr€l. <br />c- ro --75'tt'\ <br />.>- <br />coxuaucuoll"LlilD.llc [!cl <br />I hmby afim undd pmalty of p.rjury lhal thde ie a on$rucrion kndinS .8dcy for lhc pslomnnce of lhe Mrt aor shich this p6nn b <br />issu.d (Se 1097, Civ c.). <br />-l <br />cslify thar rhc rqlfal rcsulariori r.gdding dbdros ronoval are nor opplicabL lo rhE proj<r <br />I cdiryrhd I h.!r rad rhis applicarion drd srarerhal th..bov€ inlomarion Lcold.I aE.a to comply*nhallCnyand cour, <br />ordniancG dd Sktc t $ rcl,tins Io building connrucrion, and hcrcby aurnoriz. rcprsmlarivB otlhis Cilydd Coo.r!ro dr6 upon rlE <br />atl\e nrcnrn,n€d poltny a.r inspdnJ. pullsB <br />Appliclnl or ,t8etrtSt tturr x_'r"r"3:t'r-ja <br />SITE-WORK DATE ID/SIG.COMMENTS <br />Set Backs <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsulation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Irrlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Frnal Report <br />Flood Zone Certif <br />F|NAL i*// -/ //7 7,,-../f/l-./ tq <br />Certif icaie df Oc6upancy-I <br />Notes, Remarks, Etc <br />?:- <br />Forms/Steel/Holdowns <br />.{E.nt* /O-(-tt <br />1-t1 <br />ATIj.I(AdLDICIAAAIION <br />I hod,altnnundd p..alry olpqjury onc oflhc followinr d(l alions: <br />Dcooliion Ptrir! asbdos Notilication [ed6al Rcf ulatioE ( l'itlc 40. Pani) <br />R.q!n n lddoaNorincabn