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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE IDiSIG.COMMENTS (,lvNt:R BlrlLDtR I)tt,(]aRAl l(rN
<br />I hcrchy allirm u cr ncnally ol pcriury rhd I m cx.hpr tiom rhc Co lracl,trr l,i(cns If,w ntr rh. tuln wms rcrson (5<.71).11.5
<br />llusincss arl Prultrsion Cdlc)r Any C y or Cin'my whrch rcqtrtes r p.rn,ir 1(r .onstruct. alrcr. rnllrnrve. dcn$li\h or tpM any
<br />{tucrur., pnx ro rls hsuaNc- alw, rcqutcsthc 41llicatrr tur \uch Iln h lilc. sl3rc'l darcmnr rhar k dr \hc is li.ctrrJ nusua
<br />r, rh. ntuvson. ol rlE Conra.r.rs l.iccns.d llw (Chiprc' 9. Cnnmctur3 w(h Sarion ?0(D ol D'vs n t ol lh. Busircss inll
<br />Pftna$rons Codc)o! rhrr fu or shc i dr.hpr rhd.liod mJ
<br />'h.
<br />b,{s ltl rlEalkscn cichonrn Ary vd,tonoiSslion 7011.5 hyany
<br />im[.anr nx. !.mril suhjelsrhc 4Irl[Mr to r.ivilFndryol nol nxne lhin livc hoRlr.Jd.llr\ (S50o).
<br />-1.
<br />as owfti dr rh. l'Bp.ny, or my cmoloyccs wirh waecs as
<br />'h.r
<br />nn cdnrlcnsalnn. willdo lhc *orl { rltsturmirnDt
<br />mrcndcd or oltial tu $L (Sr 1x4, Bu\iEs and Pbrcsson( Cdtc: rhc Conhukn\ Litns. Lxw dcs not .pplv lo an owmr oa
<br />rhc pn,Fny wlr) huil&.i in{nitq I,EED, aftl *lx) Jes skh Mr* h,mself.r hn*lfor rhn)u3h his or h.r own cnrl,'y.cs,
<br />pmvidc,l rhar such mpormnrs N nor orcdc{ or oflcE{ nn srk ll, homrc', rh. huuin8 or impNrmnr is sU * hin onc ytd
<br />ol comnlcrin. rhc Own6 Buiu.r wiu haw Ih. burlcn ol lmvin3 rhal h. or she JiJ nor hudl or nqrorc lhc l,Npdy tu hc NrIr){ .f
<br />-1,
<br />r\ owncrolrlr t'nltiny. rncr.lusiv.lr.oorra(ri4 wirh I '..n {d .onta.ror n) condru.r rtt F'ic.r (Sc. 7044, Busncs
<br />a lhrisin Ci,J.: 'l h. Conkacktr'* L,c.nsc tjs doe\ ml ipply r, rno*nd ot In,ltay vl!) buildr or imprcvcs rhdcon.
<br />xnJ who conkads lor such Inliccrs wnh a Gn rr.r,(, h.{ {'l Pu$uanl t, lhc Conlrtn,r s Lrccn\c llw)
<br />B & PC. krrhtr rcan,n
<br />TVORKERS' CONII'ENSATION
<br />PECLABAII9!
<br />I hcrcnyrlftnruDJc! p.nrlr!ol i.rjryoncof lhc lnll winrlcclalrrrlns:
<br />I n !e an will minr.in a Ccnitt,lc or Conscnl b Sclf-lnsurc lo urke6' .onP.n{ri!,n, .s Flviloj for h, Sccrt,n -uoo or thc
<br />l-hor CoJ€, for lhc Pcrlomcc of l,r hr* ror uhah ih. p.mit h ssu.!
<br />ll havc wiu .Diflail wortcB .omrcnsrl ion insuErcc. ar t qutcJ by Str ioo l?OO oa lh€ L.hor C.,lc. rd lhc ldfomnce of
<br />hisl).mn s issu.n. Myw{ cm' lr,mpensari,n inrurancc .Micr arl pli.y nunbct ft:
<br />Sh,^\c truc' a\
<br />42\\9rt-
<br />-lr1ttrcs
<br />ztAlZ.)
<br />I ucnity lhar in lhe perio.@ncc ol tbc *otk for whrh this lcrm is tsu.,l. I dull R .mploy .ny PcFon i! in, ndncr
<br />$ rs h tEcotu suhirr rd rhc workcr' comrcnsarnrn h*s ol Califon6, atul lge nrar rl I shouu &coe bidtollE
<br />wo!*.6' c.hp.ns,r io. povsion. ot Sc.ln,n 3rOO of lhc ljhdr CoJc. I shall, fonhwirh canply wirh lnd* lmvlsiotrs
<br />WARNINGT Failu.c lo ecft *(trk s codrnsaridr or.m3c is unlawtul, anl rhlll suhiccr r. cmploycr ro uimin.l IEMllas ind
<br />h onr hundrcd rl$usmd dollar\ (ril00.0lx). in r d n b rhc c sr ol comp.nsdbn, ddm4cs N |hvidcd brlhc
<br />Sc.r(n,:1076ol rlr lrlu C\dc. mr.rcd a.J srtn,ky \ l(\0
<br />DECIdSAI]AN
<br />I hcEby dnm unJcr !.n ly ol pcrjury lhar I as li.!n{,1 un icr ,,o vi! idn or chlrtcr I (onmtuing wirh Sccnon ?000) olDivirion.l
<br />of thc Alsimss anrl Pn,rcssion! co.rc, ad ny liLcns is b tuI lb& ur.l cuei
<br />b \o) o\)\
<br />,.,\11-lu)a,
<br />CONSTRUCTION LENDING GEN(A
<br />I hcrchy trm unJcr I'cn.lty or p.iury rhat rhcrc $ a .onnrudnln lc in3 r8cEy nr rhc tt dorMrec ol lhc *otk lor which rh^ ttm[ i!
<br />r\ucJ lscr.1097. Clv. C.).
<br />APPI ICANT DECLAR-ATION
<br />I Mry ,nim undcr Fnrh y ol pcrjtry onc dr rh. nnltwins deld,ronr
<br />t).nrlirnh PcrmnrAsh.(os Notili.arn,n FcJ.Bl Rcsxlirions (TirL 40, P.n6)
<br />_R.quncd kn.r of Nolitic{lion
<br />_l (aityrhd rh. tadcr.l rcgularons Egr,lina r\lEsros rcnrvi xrc horxmlic$lc 1,,lhs pDjc.r
<br />I (nni rhar I lllvc rcld rhn .pnl(ri ion ad nar. rtur rh. rbvc inlilmmriotr is rotrccr I rgrd t, .onlPly wirh all C[ y an,l Cotrnry
<br />onlirMccslndSlalctiwsElarinAk,buJmgconnrucrdrmlhcrchyaurh.rizclgtcscnukrcsofrhsCiyandCou.ryn)cnrcruErhrh.
<br />xli,vc nrnuoncd prrNny irr insl'c.rion
<br />A Dlic$t o. A,lenl Sitmtu m
<br />c
<br />Set Backs
<br />Formsi Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsu lalion
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />l\/asonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL t\at\10 vttGn(WY7
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc.
<br />T-Bar
<br />"^",\lzlL6
<br />^,,,\lLlQ C)
<br />Lc1,l(r . NJm.
<br />-
<br />knjcr \ AJJrs
<br />I
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