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BUILDING- INSPECTOR RECORD SITE-WORK DATE IDiSIG.COMMENTS ()\\ \l;lt It Il t)LR t)t ! ( \r{ \ rr{)\ I hcrcb, nlfirm undcr pcnahy of pc{urr lh lmcxempl nom lhc Conlrack,i l-iccn\c llw f{r ric i(rk,ling nNnr (sN 70:11.5 Du\in.ss ntul Pmf.*ii,n (](xlc): Any Ciry or Cormy *hich r.+ne\ r pcnni nr .onirurr. dlr$. inpnrvc. dcnmlhh t{ rcnr any (ructue, llior ro irs rruatra. rls rcqunN lhc lpplicrr for {.h trnn ro lrh r siSmd ndcnEnl lhot hc or rhc i1 liccnrd pu^uanr h rhc rtuvisi{Jh\ .frh. C.fuictr\ Li.cn*d tjw (Ch!pr.r L Co'nnrnci'r8 *nh Sc.rior ?IX)0 ol Divhiotr 3 oflhc lrusinc$ ond Pmlcsio.s Colc) or rhar hc or shc is crcnq rhcrcir.m and rhc basis lor rhc rllc8cd cxc!ryrn'n. Anyviollri.nolSsrkn70.ll5byrny lprlicant forapcr.rir subjccGthc anplicaor lo !ci!ilpcnrltyotnor mrcrhrn fivc hundtndollqs lS5fl)) I. .s o*nfi or rh. lmlidy. or .rt cnrrlurt.s wirh wascs N rh.ir v,k .orll,'nrdrion. will do thc sorl oxl rtE (ur8 i! ml inlcnd.t orollcrcdtbrslclsa7(!,1.BusincssundPrclir{ionsCodc:lhc(i'ntactnrl-i.cnscLdwd.csno.alrlyro osncrof rhcpmFny who huilds or iryrercs rhcer aftl who des s!.h s* hi rll or h.sclf or rhmuAh his or h$ osn cmPloyccs. pft,lidcd rhar ruch ihpmvctunrsd or im.rdcl oroficrcd lor slc II hos.\rr. rhc huildirS or inprcRm h sld wilhin.nc )co oi complcrion. rhc o'm! Buildcr wiu hrrc rh. budcn ol'pnvina rhar IE or nhc dil nn bnild or iniprok rh. F)p.ny ror rhc l)urN{ or l,.so*$.frhcpm|Edr.arcx.lusivclycotr.ri'rg*irhIi..n\cd.oit..roNn)c.n(rucrrh.t'mlccl(SL!.7l}l4-Bu\inrs\ rfrl lJollssion Codc: Thc Co.lra.lols Li.cnsc Luw do$ not !p0lylo rnownc, oip6p.nr eto build\ or inpir)v.s lhcr.otr. rdd who ..nhrrs rtr su.h pmjccB wirh d coir..r,n 9 li.chcd Nrsu blh.Gn ra.tor's Lienr uw) I ancrc r|n undcr Sc.rtrni .8.&PC lnrrhirrcr\otr Orrcrl lro.BKEB!:glttlhutrul I2IICLA&IIIQN I hcrcby ilrirtrr trndcr Nnrlry.ilrrjry otrc oirltr,nll,,wn8 dccrnnrion\: ! hnvc arlwill rtun {inrCcnillcrlcofConscitbSclf.lNurclorlorkcrs.cotrrDctr\{rintr.as providcd lir 6y Sccrn, .17fl} ot rh. Lnhr C.dc. f(rrh8 p.rfortun.. ofrhc wor* fd whi.hrhc p.rmir i\ is\md. _l hilcrnd sillmrn 0inworkcrs c.nDcnsation i$umtrcc. is rcqutcn hySccrioST0Oolrhc lxhorC{nh. ntrrh. lcrrohrrnoor rhc wor( lor shichrhn pemir is tsued Myworkcc co'npcn$lion iosurrcccuicr iJtl lx,licynumh.rdc l..niryrhJr i', rhcr^-rfonunccof ihc work l* shichrhk |r{rnn i\ isncd.l slull .l c ployanyt)cr$n ir rtryDranrcr sors'oi.co.rc$rl+.rrothcrolkcr'conrpcnsdiofllassofCalitaarii.rndrsrccrhdillsh.uldbccomsbjcdn,rrr rorkc.s'con{'cnsolionpmvkionrofSc.lion.lT( ofrhc Latrr Co<l..l snall. ionhwirh conply wi!h rhov pn,vi\i(,n\ WARNINC Failtrrc ro Korc workcrs coml,.nsario..ovcmrc is utrhwtul. aid chrll \rhjc.r a. ctrDloycr ro dimiDul [rNtics ind (i!il finc\ u, b oR hdndrcd rhou\a d dollars (Slm.On). i', sddin,n b rhc .o{ of.ompcisarn[ drnr8cs !s provid.d lor lhe Sc.lon 3076 dfrhc ttrtrtr Codc. irlcNs Md.normy r rc.\ ADpli.nnll uui!,51[QN1!t!:11r8 DISJNAIION I hcr.6y uiltn undcr ri.nlhroip€rjlry rhal I unr liensd under pr.vnn,nofCh,pr.r 9 (dnnmn.in8 sirh sdrion 700(JrofDivhion.l of lhc Busincsmd PolcsionsCodc. onl nr,liccnsc k in tulliom andcli(l. Liccnsc Clars:_Lic.B. Nunbcr D.1.: conlr..to. ra!flauculrNl[NllNti-ali.ENct I h.rcby .tn n uMcr lrh,hy .r pcrjury rld rhcrc h , co.{fl.ri Llldin! rgcmy tu thc |)crformmc. of rhc nork lor *hi.h this rErni n i\sucd (S.r l(r97- Civ. C.) lJ cir Namc: landcis AddRs: - AIILIIANLDECI4IIdUoN I trrb, dfliin undcr F alr, or pclurt onc of rh. folk,winA d(l*ar n,ns D. rnni P.rmn\ Aqb.sros Norficrrdr frcdcrrl Rcgulrrions (Tilc,1{. PM6) Rc{tuircd lxricr ol Mnili.dtr -l.cnilj rhrr rhci.dcElrcgulrri.ns rc8:udinErs6({os'.Nrvrli.c forr0trlicrhlc b rhi\ pojccr I.cniryrld I hrvc r.M lhN otdihdtr.c\ rtrd Srar. ttrqsrlnri c rh r rhc rh,rc rronruriofl is .orccr I ll3r( ro conrdy wnh all Cir, rnd Counry iurhrltc rcDrcrcnr{tivc\ olthir Ciry!.n Co!trry ro cnr& ut.n rh. *,",alztln Set Backs Forms/Steeli Holdowns Erection Pads UFER Ground SLAB Floor Subf loor/VenVl nsulation Roof Sheathino Shear Wall Framinq 'Jztltt/Ar-?-,/ lnsulation/Energy Drywall Ext./lnt. Lath Masonry Pool Fence T-Bar dAolK drto//t-'6b-- Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif FINAL /V/-avt ,,o?- /1/rr/k Certif icate ol Occupancy Notes Remarks, Etc. Brown Coat I =