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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUII,DER Df, LCARA'I'ION <br />I hercby amnn und.r pe.ally ot rdjury rhal I m exmfl nom the Conlra.roc' Lice"* bw for thc follovins r.en (S( 70115 <br />Businss ud trofdion Cod.): Any Cny or Counl, shich ,<uir6 a ponir io oBlruct. ahs. improvq d@olilh or rcFat anv <br />srrucruc priorlo n, isuecc. also E{uir6lh€ applicdl for su.h Fnnl ro liL a sisn.d sldendr lhal hcor slE b licss.d pdu&r <br />ro rhc prcvisions ol rhc Conlr.clors Liccnscd tiw (Chapld 9. Com'ncncins snh sdion ?000 of Division I ofrh. Ausin6s and <br />P(aesio$ Codc) or rhai hc or sh. ir cxmB ln*nom d lh€ ba.t for ihe allq.d €xmpiion. Any violarion of S..1ion 701I 5 bv uv <br />applica,t lor a p.onit srbjrlslh€ applica loa.ivil,@hyoanormoterh fivc tundrcd &lld (t500) <br />-t. <br />d ohs of rh. proldy, or nry cmployG with was6 s lhcn eL .onp6eion, sill &, lhc "o.t dd dE stnrlu. is ml <br />i.led.d or ofidcd for slE (Sa.?044, Busins dd Prof*io6 Cod.: Tnc Conradoas Lrcor. Lr$ do6 nol a?ply to d osnd of <br />rhe plopdy vho builds or in{rov6 rh@n. md vho do6 soch "!* himsclf o. h6cllot rlmu8h his or hB os n @plot.6. <br />phvd.d rhat such inp'lvmds sc nor inlod.d or offd.d for sL l L hosa6, lh. boilding or in9rovffil is $ld wnnin on. )a <br />olcomphior rhc Om6 Buildd *ill h.v€ lh. htrdm of prcvins rhd h€ or sn€ did mr huild or in 'nv. rhc popsly for lh. purFd* oa <br />-I, <br />e ow.o oflhc pspdly, m cxclusivcly conrraniis wirh licdr.d conlmdo6 lo cotultud rh. projst (S( ?()''4. BcinN <br />and ltnli:sion Codc Tn cont.cro.s Lic.ns. La{ dos nor alply lo u os'nr o aPrcp.ny rvho builds or improvd lhdon. <br />and rno lontocls for sucn prejccls wnh a Corrrdcl6(s) li.dts d pxEusr to $c Co.tadd t-te6. tiw). <br />lm.r.mddd6s(uon .B E PC torrhtsrgMl <br />Drl€: _ Onn*: <br />$ORKFfS' COIIIPENSATION <br />DEcrdtauo! <br />I hs.nyaflim und€r p.ndlyolpojury on oflh. folloviry d.cloarionsl <br />-l <br />h.vernd s,ill mai.rain r (.nificotc olcoMl lo Self-lnsurc formrlc conrpcnsotion,6 provid.d aor bySstion lT00 ollhc <br />tibor Cod€. for rhc p6roddc. oarh. worl aor Nhich lhc p6mil G irsu.d-4"and\illilainrdin\vorkeccomp€nsalioninsuran.c,asrcquitdbvsc.rionlT00orlhcl-abor(tde,forlhetsrom c€or <br />lhc trorl for *hich lhi Fmir is issucd. My JC compeNalion i6uranc. cmid dd policy lu'nhd ac: <br />^ Ncliond i <br />>)-11WCCZ 562 o)- <br />-l.dilythar <br />in th. p.rfomdce of th. soik lor whiob this pcmi is isstr.d,I shall nol nploy any Fson h dy he.6 <br />s6robe.,,mcuhr(rrorh.*0116'.ompNrionla\cotcallanEMda{Grha'at'houldb(om.su\*rrorht <br />sor r 6 romp.Mr bn pro'isrotrs olsd rn :r 7OO ,,1 lh. I shll coite I shall. lonhw h conpl) tr h thoe po! BroN. J <br />'WARNINC: I-ailure k, su. workm' comp€ffalion covmBe is unla*rul. &d shall subjei dploF lo diEinal FDlti6 and <br />ro onc hundrcd rhoosa dolltrs ($100.000). in addnno l! rht.os ol'.ompcnelion. da.gcs a lm\id.d tor Ihe <br />Sarion 1076 ofllE lik,C.dc.iNdd and <br />DECI,ASAIIOJ! <br />I h6.b, arrm mde. p.nalry oi pdury lhal I d lie.sol u.dct Fotision oachapt6 9 (.onndcin8 wnh Selioo ?000) of Dilisio. l <br />of Ihe Rusin* dd PrefsioN Codc, od my lic6s€ is in tu ll fotc ard .fI!91, <br />[3 9gsoto <br />I tftby affm undd lollty o f Fju.y thal lh6c is . coNtruclion ladinr +6cy aor lh€ pslonndcc offi. $ort tor whi.h lha Fnil b <br />isu.d ( sd. 1097. civ c.). <br />LcnJcr's Addr6s <br />- <br />dftulANrDEclalauoN <br />I lEttry rfrnnundq pcnaly oapqjur, one ofthc lolloqins d(lsalions: <br />Dmoliioo PBmns-Ashstos Nolifi.arion F€d.ralR.atrlarions ( I ill.40. Pano) <br />-Requt <br />d Lclt6of Noli6carion <br />I (.niiyrh.r I hav. r.ad lhn applicalio <br />o'!ina..sd sr,rc t-a*s r.hrin8 to!!ild <br />n ed slar. rllal rhc abv. infonn.tion is cor.tl.I ag.a to comply sith all Cityed Colnry <br />codttucrioi. ad hq.b,.olhorizc rcpr6alaln6 of ri3 Cny &d Counly ro 6ta upof, th. <br />due Drnri,r.d |m,J,.n\ lt.r <br />".,Ju:1:/3\fl'lictrtrr r, .\lrtr( SiA rltrr( <br />t .t't/?4 t obe <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/Vent/l nsulation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />lvlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif A <br />t?ruGN- fac-l$L fl4e -tv y.Pp{)R <br />FINAL ll-11.18 y.w)t) <br />Certificate of Occupancy -/ <br />Notes, Remarks, Etc. <br />Brown Coat <br />"",.. -- ? l- 6-tg <br />u". Il --)g <br />-l <br />cdily lhar thc a.ddal fgulations Esadinr 6b.stos rdolal &. nor .pplicable lo this poj<r <br />= <br />L <br />I