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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.OiINER AU[DER DI'LCARATION <br />I h.reby afti.n undcr Fnalry of perjtry rh3t I crenpr ton rhc Conrncton Lhcn{ b* fu rhc follo*i'rg rLiern (Sc..70:ll 5 <br />Businc$ d Pmlcsion Codc) Any cily or County whkh rcqui,ca J Emir b cotrnrud, trllcr. nnDrcvc. dcrnolish rr rcnrn a y <br />drucrulc. p,ior re irs is\uancc. ahr rcquircs rhc npplEanr ior suchrrnnir ro nba signcd {at.i*nr rh,r h.or shc n liccnscn l]U6u.nr <br />ro rhc pmvkhns ofrh. Co.k.cior's Liccnscd L.w (Chtrprcr 9. ConnND.ing wilh Scdion 70tD oi Division :l otrhr Bd\irlcss and <br />Polusinns Codc) or rhar hc or lhc nqcnll,t rturcfr. and rhc h0sis tu rhc ik8cd .xcmorion Anyviolarionors(ridi70r1.5byany <br />{tlicdnr ror a pcrnn sobjcc( rhc amli.rnrk' rcivilpenrlryolnor mo.c rhr fivc hxndrcd dollrs($500) <br />-1. <br />as osrcrofihc prol.nr. or mycmDloyecs wirh wrAcs as ihct solc coDrrcDsrlion. willdo lhc aork aDd rhc (turm ir nor <br />i[.tu].d or oflcdd for slc (5*.7044. Businc* nhd Prof.ssion. C,ilcr ]'hr Conftr.roas l-i.cn* Liw dms not qrlly ro m o*ncr ol <br />rhcpmpcny who builds or impolcs rhcNn,ond who docs suc[ wo* himsclfor hcrcllor rhrou8h hn or ner owi.'npluy..s. <br />prolidcd r h.t such inrrhRmnts e no! intcndcd or.lIrB] for elc Ir, tx,wcvci th. briling .r nlptuwnrnt ( hll rirhin oE ]eu <br />or c6'npbr io.. rhc Owncr Build.r *ill haw rhe hord.n oi pnrliry thar hc or shc did ior hrild or in'ln)h Inc pn'Fty ror L\. purlt){ or <br />L aso*mrofrh. pfl,pcn y, ,nr . xclu { iv.ly .onta.r ing *nh liccnscJ .oora.trs r. sn{d.r rh. pmic.t (Scc.7044. Busr.c$ <br />and ltnri$hnCodc: Tte Conrncrols l-iccnsc Low docs n l.rplyIo!nor.crofrrop.ny*hi)buildsorimp.ovcsrhercon, <br />und wh..o.rhchforsuchl,ft)ickwirhrConrn.rods)lken\cdrxnunrrorhcConltucror'sLiccnscIjvI <br />lrtrrcrcifru d$Srcri( ,B &P( ntrrh'\rcrvrr <br />()qmr <br />TOAXE&L(OUIINIAIION <br />DICLAXAIIO! <br />I hceby atr'iro udcr pcnrlryolpcrjuryo.c oI rhc lollosine dNl.r ions: <br />-l <br />h.vcudlillnun airaCedirEarcofcon* nr Sclf.lnsurc lbr sorkcs mnqrn\ario!. !s p,olidcd lor br s.crion]70o or rh. <br />tjbn Codc. for rhc pcrfoirmRc of lhc {ork for whi.h rhc Frmir i\ issucd. <br />rh. *ork tur*hich rhn p.nnir is tsucd Mr*ort.rr con,p.nsxrion insuran.c caricrrd F'|i., numbrrr. <br />Policy Number-Eitt*: <br />l.cnily rhd in rhc p.rfo'Mmc.rrhc Nork for shich rhiq r$mii i\ hsu.d. I shlll tror cmfloy ony p.rcn in rny manner <br />e N b h.snE subjNl to rhc workcG' co mtcn sal ion laws ofc.liforni!. md 08e lnar ill sh.uld bccoft subjccr ro rh. <br />workcrs conll)cnetion ,mvGions ofSccrion lr00oithc Lrbor Codc.lsh.ll. r'onnuirn conply sirh rhoy pn,virn,ns. <br />WARNINC: f{ilurc ro scurc ao*cB ompctrs.tio. covcn8c,\ trnlaeful. rtrd shall subjccl an cnrDloycr lo ddinal p.iahics rd <br />ciril litrcs up to onc hundtcd thousnd dollan lsltu,ou)), h rddnion lo lhc cosl o f coflrpc osar ion- danDE.s as riolidcd rr, rhc <br />Scclion :t076 ol lhc Lstnr Cod€. inrcEsr and arlorrcy s lecs <br />ApDllonl: <br />III:EITIELCONIN6!]IQB <br />DSCLAf,AIIgX <br />ol rhr Bu\ir.\snnl t'mli\\i,,n\ Colc.Ixt n,y lir.tr\e is in tnlllnrct rntldll..r <br />CONII&JCUONIIIIINCIIiINII <br />I h.rcby Jtum und.r lxn,lry o r p.ijury rhar thcrc is n.on{tu rir lc.din8 a8crcy in thc Frfonuncc ofth. wo,k nn whnh rhn Frmn it <br />hsucdlscc 1097-Civ C ) <br />AIIIIIAIiLI)IEI,IBAIIOI <br />I trr$y llnnu dcr lEtulr! .1 lf,lury onc of rhc i( 'll,'snr8 dc.llnrn ( <br />Dcix'liti,m Pcrnih A\bcdo\ Norificrrnnr Fcdcrnl Rcguhrnnx iTirlc.l0. Prn6) <br />Rcqumd lrrrrr ol Norii.rri)n <br />-l.cnirylhrl <br />rhc tcdcrr I rcBu 1.1 ions rcE{din8 $bcsos removrlarc roi uplicahlc ro rhis pnrrcrr <br />I cdifyrhd I hrvc r.ad rhis rprlic ii,nmd ndcrhd rhcatxrc inforuion s.oft..r tiprLrbcotr[lyairhollCiryandCounly <br />o,ni'[i..landSrnrcllwselnringbhildi'rgconn.ii{n],ddh.rcbya h.ircrcfi.s.drrivcsolrhhCnyaMCounryrocnlqlIi)nlhc <br />.bovc nEnlioncd nm!.ny for insfetion purp.scs <br />,\pDli.ani o. AEent Si8n.lure: <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />SLAB Floor <br />Sublloor/VenVl nsulation <br />Roof Sheathing cllls U ,C,rta-z+t l.+'L<t <br />Shear Wall <br />Framing <br />lnsulation/Enerqy <br />Dr){wall <br />Ext./lnt. Lath <br />Brown Coat <br />It4asonry <br />Pool Fence <br />T-Bar <br />Handica p Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL 7/L/tq ,{K@/n> <br />Certilicate ol Occu n <br />(L <br />COMMENTS <br />UFER Ground <br />Notes, Remarks, Etc. <br />t ndfl r Addrc* <br />- <br />---r------ <br />I