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SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CAR^TlON <br />I hseby amm uod6 poalry of pdjury lh l €rcmpl liom lhc aont.clols l-rc."i. hrv for lh. follosinB rcMa (Sc.7oll5 <br />Busins ari Profsion Cod.): Any Cily or Courly *hi.h icqund a p6fln to connru( ah6, imP.o\c, dc{olth or r+at My <br />*dc1uc, pritr lo ns issu&ce, aLo rcquird lh. applicml lor such p<nnit lo file a sisn.d salEnot lhat he or sh. i licms€d pu6udt <br />ro Ih. pmvisions oith. Conl.acloas Lic.ns.d Llv (Chapld 9. (om.ncin8 \virh Sstion 7000 oaDivisiofl I otlhc Busin€s ed <br />Proa.ssio,B Cod.) or lhal h€ or shc t ex.ipl rh6.6om atul fi. b6is fot lhe allesed cidnprion Any violation ols€crion 70ll s bv anv <br />oDplica lor a pcmil subjds rh. applicam ro acivilpflahyotnol no,ethd nr.hundr.ddollds($500) <br />-1. <br />s otrnd oflh. prop6ly. or oy edplorG wnh wt86 s thcir $le conpdsalion, sill do lhc qork a{ th€ slBrr. t ml <br />irraded or orI(qj hr sL(sd.7044. gusins dd Profsios Cod.: Tllc Conlraclois Licsc tis &d not atplv to u osr(or <br />rhc pmpdy trho hikh or inFov6 thdstr md sno dc su.h s!'l hims.lt d hmll or ihrolah his or hE oM dplort6. <br />prolid.d thrt such i,nprcvmts Ec @1 iddddl or of6.d for $1. I I no{6's. th. blildins or inpmvffil G sld *ithin on ta <br />oacofrpldion. rh. Omd Buildd will hale lh. hnto of prcvins rhd h. or sh€ did nol hrild or i,qtoic rhe plpsly for lhc pu4bs oa <br />I. 6 own6 ollh. pspsly. €xclusi!.ly conlracrinB *nh licmed cont,aclou lo .oi.ltu.l rh€ Ptj..l (Se 7044, aas6 <br />aad PD65sion Code Th. Conlrscloi s Liccnse Law do6 nol agply lo d ownd of rrop.n y *ho builds or imProvd thren, <br />ad *ho .of,lmds aor sucn pmjtds wnh a Coira.lotls) li.6s.d pu6@t lo rhe Cohtr.dois Liccc kN} <br />-l <br />m .rdpt mda Saioi- B. & P.C. for this ra$n <br />Drle: Ornd: <br />,UqAI!!'BI-1:OUTENIAIANu!cl!1-8ll!g! <br />I hcr.l,l amnnuider pe.ahyolpojuryoncorrherollorvinsdNlr i.rs: <br />-l <br />navc dd *ill maidah . C.nifical. oaco.Fr ro Sela-Irotrr. for \rcrtss cotupenslion, s prorided aor by S<! ion I700 o I th. <br />t,bor Cod€, lor rhe pofotlmcr oart. "ort fo, which lh€ p@ir 6 i$udl <br />I har. ed w ill ,nainlain work..t cohrasario. imurtncc, s r.quircd by Sdnon :1700 ol the kbor Codc, lor lh. pdfomuc€ ot <br />is isn6l. My workgi conrfasatjon r6urd.t ffid md lolicy numb€r a.: <br />o t-l -22/f <br />-l <br />c.nily rhar in {hc pdforroncc ollhc wort lor shichrhis Fnn is is €d.l shall nor dnploy tny p.ren in any n@d <br />$ 6 lo b6o'nc subjel lo lhc "orld' omPoslio. l.ws ol Caliloml4 ed a8r rhar if I should b€com. subjd to th. <br />NorI6' comr,delion pmvisioc of Sdtiod l?00 ofln€ L{bo! Code I stBll. fonhRilt comply Nith lhos Povisions. <br />W RNINC: Fanur. ro su. workds' compselion covmg. is unl,sful, d shall subj<l a. dplo)€r lo oimtal Doalrie md <br />civil fin6 up kr one hundrcd rhols d dollss ($lol),Ctro), in addirion ro llE con of conpcMriod. dana8cs 6 provided for th. <br />Strtion 1076 oarhe Labor Cod€. i.ldd ud <br />I hftby .fim und.r p.mlry ol pdjury $d I aB lic.c.d lndr povision olchapra 9 (conmdcins $nh Saiion 7000) of Division 1 <br />of the Busins dld Profsions Codc. dd oy licoe ir in ftll forr .nd €iIEt <br />.A 1L <br />coNsrauulatLlitu&G-dcrNcl <br />I hercby amrm unds p.hahy o f pdjuty lhar lhdc is a conslru(n n hdid* agdrcy ior rhe psnrnnm.c ol rhc \ ork for * hi.h rhb ptrnit is <br />issucd (s.\ l()9?. Civ C ) <br />ATTIIQTILDICIJSAIIOIi <br />I ttdth, amnn undd p€nalty ol p6jury o.. of rh. follo{in8 dalod tuns: <br />Denrlirion Pcmirs-Asb6r6 Norincalion rtdqal Rqulaltuns (Till.,l0, Pd6) <br />-Rcqut <br />d L.lto of Notilic.lion <br />-l <br />c6li& that lh. Lddal rcsuLtios rcBedins sbalN rooval e not appli.abl. to rhb pmjdl. <br />-l <br />cdriry rtll t h,!. @d iti3 applicalion old slar.lh.| $c lbon inaomalion iscor.d.I arc lo omplv silh.ll Cirva.d Counlv <br />ordinanc6 and Surc lavs Elatina I nc olrhis Cilyud Coumy ro 6rd upon <br />abo\e,noli.ned prop.ny lor <br />,\pt'lictrtrr o, <br />^srir <br />Sis rhr <br />bur ldiDS .odrud 0,. ud hr.h. r h.ri7. r.nr6lrhr <br />furE ,,* t/- za - t6 <br />Set Backs <br />Forms/Steel/Holdowns o I ).. lo( .e./tt -rx <br />Erection Pads o{)/ '' A!) <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenUlnsulation <br />Roof Sheathinq <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL l/zr/rO -{/zz4t 7?.) <br />Certificate of Occupancy <br />Notes, Remarks, Etc <br />BUILDING. INSPECTOR RECORD <br />Pool Fence <br />,,^,", ll- zL- to <br />-2-L- t9 <br />tt