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l <br />BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS <br />DE(TA8AIIQ! <br />I ba.by allmn unds pdalr) oatGjrry on. ofrhc foUowins dcldarios: <br />I lEle a'd will naiorain . Ccnificatc oaco.mt to Self-lNurc ro, *orkor .onrpensrrion, 6 previded a.r by S(rbn 1700 of th. <br />Labor Codc aor lhc pElomac€ o t $c worl for qhich thc pmnir is issued <br />,ndNillnraimainwork.rscomp€Narioninsuranc,srcquncdbyScclion1700ofrhcLabor(ode,Iorlh.pFaonna.ccol <br />r.' (l'nI rl'ir mnnit n irsu.d.?-+__/_-> -1, ,/1--..1a\ <br />n insrance cd's dil E)l'cy n0mb€! ec: <br />M*' <br />V' <br />qeoq166 <br />I ceniryl[d in the pqformarcc ollh€ work aorshi(hrhispcmn is i\sucd.l shallnot enploy.nypsson inanymMnft <br />s, 6 ro bsone subj(t lo Ih. sor*m' .ohpcNarion laws o I ( rlifomi.. md .sre Ihal il I should berom. $bjd ro rhc <br />r0116 cohD@tiontmvisioG ofS*rion lT00ofth. tjbor Code.l sl$ll. aonhwilh comply Nirhlho* Uo!isioB <br />WARNINGT l;ailurc lo surc sortd .onpqsari('i cov.6ge n mhlvful. and sh3ll subi(t an mPloyd ro diminat p.nalri6 .nd <br />cnil fin€s up lo onc hun&€d lhosud dolld ($100,000). in addnion ro lhc dtuna!.s d providoi lor rhc <br />od., inrcrsl ud dnonFr's <br />[;." <br />DECI,AMITAN <br />I hftby amrm und6 perally ol pdjury $ar I e licos.d u.dd ,6vision oaclfplE 9 (conmocins wirh S.dion 7000) of tlivisiotr :l <br />of th. Busins &d PrcfshN Codc. od fty |i.tu. Ls in rull 6r.. dd €fi{rl <br />ffi b <br />I heeby alItrn utu16 p.nahy of pdju.y lnd thr€ is a co.struction lmdins orocy for lhc pdlontdc€ oa the work lor "hict lhN pof,il h <br />isu€d (Sd.1097. Civ. C ) <br />ATTIII;AIIIICIA8AIIQN <br />I hgetr .flim und€. pdal y oa pqjry onc of thc lolL$rg dcldarions: <br />Denoliiion P€rnrits-Asb6tos Nolificalioo F.d.ral R.sulalions iTnk 40, Pd6) <br />-R.qutcd <br />Lerrq of Norilicalion <br />I ..nil, rlhi rhe acddal re8ulatiore !€s dins 6b6kr rcmoval tr. nor appliLablc ro rhn flnj..l <br />I crril,i rhir I have read rhis appli.rti.n e $rcrhd$catxr!.nr n is.ord I agero co'nply Nirfi allCnyand Counry <br />ord'nanc6 and Srate LassreLrin!ro buildi rcFr66nar n 6 oarhn ( n! dd Co <br />aborc nEnrion€d p.open! for <br />Zpprhrnr or rgtnr signar', <br />\P.mxe <br />nrne (prin0:9 //= <br />a <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf Ioor/VenUl nsulation <br />Roof Sheathi ng t>l"tlt€,Z7/1.;(/) <br />Shear Wall tilr,thc?,L415 <br />Framing ffi7 I *t4W <br />lnsulation/Ene <br />D II <br />Ext./lnt. Lath t /z/r'1 ,t l81t) <br />Pool Fence <br />T-Bar <br />Handica Req <br />De U Final Re ort <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL Z/2./ta e*YAi <br />Certificate of Occupancy ,- r acl <br />Notes, Remarks, Etc <br />avn <br />t, <br />Brown Coat <br />Masonry <br />OWNER I}UILDEI' DI),CARATION <br />I hd.b, altm under p€.ally or pcrjury rhd I an dcnDt fmm rh. Co"tEcloB Licens. hw forrhc lollowins cen (ss.7q1l5 <br />Bsin6s an<t Proi*sio. Cod€): Any Cily o, Counly {hich rcqutB a Frmh lo o[druci. alrd. inprove dorclish or rcpan ey <br />srucluE prior ro its isuecc. also rcqut6 lhc applicMt fot su.h p.nnn ro fils a sistrqj sl.lcmdl Oal h. or slE is lictr.d puNel ' <br />lo rh. pmrnioro offi. aontmclois Li@mcd Liw (Chaprd 9. Comnmcing wnh S€clion 7000 otDirtion I otlhe Busins ed <br />Proasio Cod.) or thal h. or shc is cr.nfl rhd.6om md Ihc bdn io. $c alles.d .rdp(ion. An, violarion oasc€lion ?01Lt by ry <br />.pplr. fo!ap.m n,bjds rhc applicol to a civil p@lty of nol ,nor. tho n!. tundred dollaB (5500) <br />l. s otrrs of lh€ proDqly. or my mplott6 with sa!6 6 rh.t ele compsdion rvill do lhc $ ort dth.$rucr@b ml <br />i.roddl or ofid.d lor sle (S* 7014. Busins ud ltorsioB cod.r Inc Conlrtcror', Licre Lns do6 no! tplly io e own6 ot <br />rhe l,trpdy who boil6 or iDpo!61h66tr ad $h. do6 suct md( himselto! hdlf or lhoush ib ot hd own.mployc. <br />proridcd thal sucb inprovtMrs @nol inGdalo.oil6.d loreL li hoN66,lh. hlildins or imrm\ml is sldsnhin onc v@ <br />ofcompl.lioll. lh. OMd Bu'ld6 will hart dc buda oaptovnE lh.t h. or she did mi Luild or i!qro\! th. FoFl, ror lhc Pnpo* of <br />-L <br />e osrd of rhe p opoly, ur.rclusir€ly commcrins wilh lico*d conlrado6 ro .oNtdcl thc p.oJe.l (S< 7044. adi.N <br />d fi!fi.sion Codc: Th. Conl.icior s Li.cnse Law do6 nol apply ro e os.d ot Eop.ny who build! or improv6 lhsmn, <br />a who .ontmds ior srch pmjcG wilh a Clntado(s) li.4ed punudl ro Ihc contccroii Licsc lr*) <br />l detdd ndd \dri.n B & P.C. tor lht '45or <br />6 <br />t enJd'! Addr6