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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE tD/srG..COMMENTS OWNER AUILDER DEL('ARATION
<br />I hrchy arfim undcr rnallv oiD€riury lhal I an .rcmDl froh rh. (onrraclon License Lae ior rh. follo\rinC lwn (Sa.7011 t
<br />Bu.iBs rrd ProaBsion Codc) ny Cily or County rvhi.h rcqunB r pennil lo consrruci. all6. nnprore. donolish or repatr m,
<br />srnrclurc. pnor ro ns issuarc. al$ nqut s lhc alplical for such pcnnir lo tlea signed slalqc fial hco. she ir licdrd p6udr
<br />to rlr trolisions ofrhc Cont..toas Licens.d Law (Chapter 9. Commcncins wirh Serion ?000 oaDnision I oarhc Buine$ md
<br />ProLsions Codc) or rhal h.orsh. i. cxonpr rhoclruD Ud rh€ bssis aorrheallcsed cxmpldn Any violarion o I Sd ion ?0115 byany
<br />apphcanlao.ap6nilsubjNlsth..pplicanltoacivilp€nalryoln6lm.nrh..fiv.huddreddollds($500)
<br />L as oNn€r ol rh. pr.t ny, or m, .nployc6 tr nh {396 as Ihcn sb comp€tration. vill do rh. wort d th. srruclE s nor
<br />rnrdd.{ oro,I6cd lor ele (3{.70.11. BuinN md Ptol6sioG Cod. l he Contracloa s Lice@ Lls do6 nol 6pply u ow6eoa
<br />thel,opdly rvM buil& or i,nl,ov6 rhcro( aid who d.6 such *orli iinsellor hcllorlhrough his orhsosr cmploy..s.
<br />povidcd lhar such iml, ovon., s rc ml intfld.d or ofield aor elc l[ lrtr6 6, thc buildin8 o! imp olarc is $ld silhin on€ yw
<br />olco,npldioq tne Orh.r Brildd GU hav. ft &ndd oarovins th.r hc or sh. dA nor build or i,nrftvc lhe poldi, for rh. pu4!* oa
<br />l. a orvnr or the Fopdy, an €xcl6'lcly contraclin8 rvilh lic.nsd .onuacloE lo oN]ruc1 rh. projecl (56 70,14. B6inB
<br />a.d hDGsion Codc: r n. (bnlracroi r Licdsc L.q doB.ol applt ro d ownd ofprop.nywho builds or improvdltdon.
<br />ond trho c.nrEds aor iuch pmjc.rs hth ! Conrraclod, li.ensd puB@l ro rhc Comncrors l-icdsc lls).
<br />I dn.xcmB udd sdrion_, B. & P.C. lor this r.6oi
<br />!qatse8l:l0u$s-ta.!a!
<br />DECIAAAIIg!
<br />I hrcby amm trndcr p.nallyolll{luryon€ ofrhc followi.g ddl@lioB
<br />lharcmd$ill6aimai'r.ceifi.arcoacohscnrroS€lHosurclor$brkcre'cdnrpensdnnr,6rrovidedlo.byseri.nlT00ofrhe
<br />tibor ( od.. aor Ihe pEforhec. oalhe *ork fo, *hich thc pmit is issued.
<br />_l have and will hainl.in *o.I€r! comp.Bation iNuranc€. s .€quned by SslioD lT00 of rn Labor Cod.. for th. psfomBncc ol
<br />t11.{L'Ilo,s\rctrhsp.mrssu.dVy*o,rsrcompdsioninqurm.,mamdpohrnu,rb6d.
<br />._,., . J $.- l- F., " J
<br />1t y 9t t, /'t--J/'/7
<br />l.dilyrhd inlh€prfonnanc.oirhetrork lor shichlhisp€rnrll is issu€d.l shall nor mployanyp€Mn in anymlnns
<br />s 6 Io beomc subjN' lo th. mlt6' comFer io. laNs ofcahaodia. ard a!rc lhar if I shorld b..aft subjdr ro rh.
<br />NorI6' coinpssalio, pro\ isio6 oi Sstion 1700 oarh. tit r Code, I slall lonh{nh conrpl, sirh fios pmvbioro
<br />WARNINC F,ilule ro *u. *ork6 coop.Bation covms. is unlawlul. ud shall sDbjd an mployo lo d'nin.l psu[i6 and
<br />.iril fincs up r.r one hundied rhlus&d dolld ($100.000). in addirnnr ro rh€ cosr olco"pcnsarion. dmar6 &s porided aor rh.
<br />Sc.ltnr :1i176ol rhc l-ilrtr(i{1., i cr.:r.ndnnonj.y 'I [^l-, f]-^L.,-r,r",''l / , /f,
<br />IICINSED-CQNIAACIOB
<br />DICI,AMI]AN
<br />I ho cb, aflim undq Fnahy of lsjur) lhal I dn lic€ns€d undd Fo\ision oachapr6 9 (co,nnE inB rvilh Sdion ?000) of Division l
<br />ot lhc AusinB Md ProfBsioB Codc, dd my license ir in lull lore dd €fi*l
<br />')8)
<br />orre I lt 7 tP K
<br />I h6€by aflim und€r p.n.lly ol prjury thal lhd. is 0 consrtuclion lodihg asm., aor the p6fomec. orthc lork for which tijs pcril is
<br />issucd (S( 1097. Ci! C).
<br />IItUcANLD!;ClltBAlloN
<br />I hodryammund6 pcnfllty olp.rjury one oflhc lollowing d(lararionsl
<br />Dcmo lition Pdmils-Asb6ros N.i i6c.tion rodd{l R.*u larions (Tnle .10, Ptu16)
<br />Rcquted Lelt6 olNorifi cation
<br />I cdily rhar rh.l€d.ralrcluhlioB cgadi.g ab6rG rdnolalarc nor appli.able kr lhis Doj6t
<br />l\C-,o '*, '
<br />*.. **,'
<br />5,-,t.,** i.a s"'. r"".,.hisapplicalionedsr.rcrharrhcah{.iin,nn,rn riscotrdr Irriet)..mdtsirnall(-nyrnn(ounry
<br />ryy"hcr..1,ydtrrr'o'irc,cln6cirdn$ulrIis( irradi(in,r\n,crrd 0n f rhc
<br />at\i!c nr. {id'cd pR,pdly
<br />,\pplisnl or A!€nl Sigo|>( l\% J.,.,C4..-e-
<br />IP
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />U FER Ground
<br />Subfloor/VenVlnsulation
<br />Shear Wall
<br />Frami ng
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />ftilason (y
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />En gineer Final Report
<br />Flood Zone Certif
<br />FINAL 1/tqltq'Dr ahb"?ra4 2)
<br />Certificate of Occu anc
<br />Notes, ftpmarks, Etc..
<br />t(
<br />.+
<br />SLAB Floor
<br />Roof Sheathino
<br />Pool Fence
<br />)
<br />l-etrdcisAddr6s
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