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BUII-DING. INSPECTOR RECORD <br />ID/SIG-COMMENTSSITE.WORK DATE <br />Set Backs <br />Forms/Steel/Holdowns <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsulation <br />Shear Wall <br />Framin <br />lnsulation/Ene <br />llD <br />Ext./lnt. Lath <br />Brown Coat <br />Pool Fence <br />T-Bar <br />Handica <br />Final Re rtDeut <br />En ineer Final Re ort <br />FINAL <br />Notes Remarks Etc <br />OWNER BU!t,DER DEL(ARATION <br />I hseb amd u.dd p6.lry ol pFjury lhar I m .x.mI fronl lhc conttdos l,'cenre La* tor rh. followinB rcsn (s..70115 <br />Buin*s md Profsion Cod.) Any Cily or Counry which rcqune a psmir lo coNrud. all6 imIrorc, dcmolish o, repan aiv <br />shcruc. pnor ro ns GsuMc.. rlso r€qun6 lh. tpplicer for srch p€mir lo lil. s siSned slaldot rhai h. or sh€ is li.ms.d pu6u t <br />io rhc provisioB otlhe Coortacrois L(.n*d ljs'(Ch.pld 9, Co'nncncins $nh serion 1000 or Divirion 3 olrh. BusinN sd <br />Prefc$ionsCode)orlhatneo!shcis.xc,nprlhdefromandrh.bsisforlheallesede€nflion Anvliolalionoas. ion70ll5bvanv <br />.ppli. r for. p€flnil subjclsrhe applic"nl lo acivilpc@lryofnor morclhe fiv. hun&.d doum(5500) <br />!. N orqs oi lhe pmp.dy, or ny ondoyG $ hh w.86 6 rhen rb composlion. will do tlE rvork dd th. sltudr k nor <br />inld jed or off.red fo; ;b (s(.7044, BNinG md t]ol6sioc cod. Th. co.tacroi s Li..s t v do6 nor applv lo o oMer 'lrhcpop€ny sho buildsor inpm6 $@n. dd wlto do6 $ch {o* fiimsclf or h6df or throush his orhd oM.mphv6 <br />Fov'dcd rhd su.h improrodrs 4 6r int.nd.d ot oir6.n fo, el. lr, ho$6s. thc tuildins or n+tov.n6t is $ld winin onc )@ <br />;tcompkrion. rls oms Bu dq wiU ha!. th. bndm of pmvios lhal hc or 3hc did mi hrild or itr{ro€ $. propsiv aor rh. Purpo* ot <br />-1. <br />d o*rd oarh. Frpdy, m cx.lcircl, coolraclins rvnh lic4{cd .onlmdo6 io Qdltucl lh. prcien (Sd 7O&, Arind <br />ud PF6sion Cod. ih. conlr.clois l,iccns. bv dod nol apply to uowner olpropelv rvho buil&or impror.s rhoon <br />a.d $ho conkcrslorsuch projet silh a Contrlo(s) li(B.n prBuanl tolh.(onrodois Licd* Lrw). <br />_l d.r.mpt undd S<tion <br />-, <br />B. & P.C. forthis reern <br />WORkt'RS' COIIIPENSA TION <br />DECI,AIAI&! <br />I hftby alfim uoda pcnalty of pqjury on. oflhc followins dsludions: <br />I havc a'd will @imain a Caiificar. ofconst io S.lf-lnsuE lor work.G conDcns,lion, s pmvided for bv Sdrio. 1700 ot lhc <br />bbor Codc. for lhc pdfol]@cc of lhc vo* fo. which ln. ponil is i$ucd <br />-l harc and *ill moiorain work.R comp.Nlion i.sud.ce. s rcqrncd by Scclion .l?00 of lhc Labo, Cod.. fot the pdlome'c of <br />.I.hr.Nrion iNuran c cund md polict nunbd d. <br />->+I f,9 <br />9oa a\6 /r /,1 <br />I .cnilvrhar ia rlr perlomanc. ofrh. trotk lor rvhi.h rhis p€mn is issoed. I sh,ll nor onplov an, pcern in <br />b th. vort6 .odpdsrion laws ol Caliaodia. d,8re rhal irl3holld becomc aubdr ro <br />wo![6 co <br />' <br />n p6ler ion p0visions olssrion l?OO oilfi. trbo! Codc,I s\nll. fontsnh.o,npl! reithlhoFpor:irio.s. <br />\lARNINC: Iailure lo KUrc $ofi6j comlE@riun <br />.ivil fiics up lo one hundrrd rhotrsa doll s ($100 <br />.ovdaB. is unla\etuI. dd shall strbjd d ploy{ lo oin'.al p.ulli6 rd <br />n. d.nrs6 6 pioviJetrl tor the <br />Sdion 1076 olthc I abor Cod.. i.isd and <br />(6 <br />I hd.by artr,n tr.d6 p..ahy of rerjury lh.l I m licenEd uod.r provision Chapr6 9 (coDn6ci.s {nh seiion ?000) ofDirision l <br />ol rhc Busin6 Md Pof6sioB Codc. dd my licase i3 in tull for.c ed .fi(t. <br />(-LL6 I ll <br />zfi/etf19 ,." <br />CONSTRUCITON I IiNDINC AC}'NCY <br />I hd.5y .mm undq p.nahy ol r.rju{_ rhar lhsc is a coNrtud ion lddins asdcy for lhc p(fomdc. of th. wolk for which rhis psnn 6 <br />isrued (sd 1097, Civ C.). <br />L.nlei! Nam. <br />- <br />Lctrder q Addrs: <br />- <br />A.EIIICANIDICI.ABAUA! <br />I hcd', .fm undq pdalty oa pdjxry onc ol thc illlo*in8 d{ltrarioas: <br />D.molition Pgmirs'Asb6tos Notification Fcn@l R.grlarions (Tnle 40. Pd6) <br />-Requncd <br />Lcnd ol Noilicdion <br />I cdify rhat rnc fedr, (sularioG r.srding db6ros rmov., e€ nol alplicablc lo lhis prcjccr <br />I .difr rhar I have lqd thii applicalion ud srale I rhe abore infomlion is cotrEI. I agrd lo comPly Rnh aU cn, a.d Counl, <br />ordinrncB dSratc I!$sr.larir8to buildinr aurhornr r.pr6olaliv6 oirhis cily md Cooryto o16 unon th. <br />ahvc r.Drioncd propeny ln nsperbn <br /> DDlic! ( or ,\A.nl SiBnrltr tA elr <br />Erection Pads <br />Roof Sheathinq <br />Masonry <br />Flood Zone Certif. <br />5\9,7'l)Ut;14 n lZ.4t/t', <br />ti-/lt lict S.NAT <br />Certificate of Occupancv <br />f,t'.t <br />I <br />I