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BUILDING- INSPECTOR RECORD <br />SITE-WORK ID/SIG.COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsulation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />Handicap Req <br />Deputy Final Report <br />Engineer Fjnal Report <br />.t*,-" ^ ltFI NAL 1,rrB ar) <br />Certificate of Occupancy U I <br />Notes, Remarks, Etc <br />+ <br />OWNERBUILDER DliI,CARATION <br />I hercby aflimr unds poalty of tdjury lh.l I dn c\dnpr liom lh€ ( onr.cto^ Liccns! ti\ for rh. followin8 EMn (S(.?01 1.5 <br />BNin6s and Proasio. Codc): An, cny or Counr, stich r.qut6 a p€nnn to cotrsrtuci. .1t6. nntrolc. d.frolish r rqEn ry <br />snlctulc prior io irs isru ce. also requtB the applic r tor such pcmit ro filc a sisn€d srarndr rh.l lE or sfu is liccnsed p6umt <br />io th. Folisio6 of tne contr.cto.s Li€enFd Ln\r (chaflo 9, comm.ncing wnh Sdiotr ?000 of l)ivision I oarh. Busin*r ed <br />ProLsions Code) or lhat heorshc is excmpl thr€lron and th.bsis forlhcallcscderoflnJn Ant!ioldtionofSc.lionT0ll.5byuy <br />applicdr lor a p6frn subj@Brhe rpplicam ro a.ivilpc.axroanor norelhm fivc hu.drcddolla6($500) <br />l. 6 owncr oflhe proFny. or my cmployG rvilh Nas6 6 rh€t $lc compasalion, *ill dd ir s ork dd lh. slnrlG. is nor <br />Dtod.d or oflqcd lor elc (Se 7044. Rusin* ed lrolsions Cod.: Th. Conr.clois Li.m. ta$ do6 nol apply to o owncr ol <br />rhc Frp.ri, \rls hril& or inprovB thson, ud Nho do6 such *!rl himselfor h6.ltor rhtuuah his o. hB o\n.mploys, <br />prov'drd rhar such inpmvdEnrs m nor inhd€i or ofdrd for $L ll no\v6 d. lhe b{ildins or iDprevflol is $ld wirhi. onc let <br />otcoDplelion. the Owe. Ru dg will hav. lh. bud6 ollfovins lhd h€ or she did not bild or nnprov. fie p,op€ly lor the purF* of <br />_1, a oMcr olrhc pmpdr. m d.lusilcly cohhdinB qnh licm.d conirrtoB to conshrr r hc r.oj.cl (Se 70.14, BL$ns <br />od PFfesionCod€:'l h. contrcrols Liccilc Law do6 nor dpoly ro d o$n6 ofF.openy who builds or nnprov.s rhadn. <br />and who cof,racrs for sucn pmjdswith r Conrr.cro(s) lica*d puB@r ro rh.Contlcloas Lk.e I2w). <br />_l an.xe rp( undes{tion_. B & PC. ao.rhisreason. <br />Drte osncr <br />woRxERs; aollrPENSATtoN <br />!&c!.axAllQ! <br />I hd.by afiim trndd pemlty of pGjury on. ofdr€ tollorinB delmtioas <br />_l h.!c dd will daimain a cdiar.al. olcoBdr to Sclf-lnsrrc lor \wrker!' cotup.nsarion, 6 p.ovd.d lor by sdrtun 3?00 o alhc <br />libor Codc. ror lfie psfolr@c. ofrh. *orl for trtich rh. p6nn i! isuai <br />_l hrvc ,nd will m.inlrin work.G comp.Balion insra.ce. s r.guned by Sdlion l?00 of Ihc L!t{r Code, aor lhe pdfom ceof <br />rh. *ork aor shkh thi! p(mn is isu.d. M, worlsi .om!.Mio. i6urMcc cuir sd Flicy nu'nbo de: <br />-l <br />csriry thar in Ihc pdfomecc ol rh. vo flr *hich rhis p6mn is issu.d. I shall nor onploy any p€Mn in dy Edn r <br />$ Bro bdom. srbj*t lo th. Mrtc'comFMion lawsolcaliaomi4 ud lrrelh ial should b.<on.subjel lo th. <br />mrtm' compcNotio. povisioN oasslion 3700 ol lhc kbo! Code I shlll, lodhshh onpl, *irh lho* pmvlsions. <br />wARNlNci Failr. to cu. worte6' comp.Gdion covcmse is unhwtul. ed shall subjet d dnplord ro sinirul pouhiB ud <br />civil finB up ro on nu.dr.d lhoMd dollm (ll@.000). in addilion lo lhe osr of co,np.@lio.. d.na86 6 provid.d io. rhc <br />sd1id, t0?6.lrh.l.lnr (-.(1. inrered.nJ z <br />><l-t\Q <br />IIICIASAIION <br />I hdeby artrm und6 p6ahy ot Fjury that I e liccnsdj unds prcvi.io. ofchaqs 9 (commacins wilh Scdion 7000) or Dirision l <br />of rh. ausins ed Prol6sions Cod.. !d ny licdsc is in full forc. od cltd.,& <br />n -( -tE <br />c.0 sIaucIr0NLENDlNG-dcli!.cI <br />I ficreby ailtrrn undd p.nalty o t p€rjury Ihal lhse is a .odNclioo Endi.s aBdcy for lh. pdfommc. ol lh. vort for whi.h rhL t6frn i. <br />isuen (sd 1097.civ c). <br />AIIIII;AAI.DDCI,AsIUOX <br />I Eq* amm und6 pcnalty ol r.dury on. oa rhl rolknvins dftlda' ions <br />DcnDlitioo PdDils-Asbeslos Nolifrcalion l_.dqal Rqulal ions { rnk 40, Pon6) <br />-Reluir€d <br />lnls olNolifi cation <br />I cdify rld rhe ledcral rcgulal io6 r+ddine 6b6ros rcmoval 6e lor aprlicablc ro rhis p(jdl <br />I ceriay rhar I h.v.,od rhis appli€alion ud starcrlEt rhe abov. inlonnartun is coder. I alieb.omtly siih ill City a.d Counry <br />ordinan.B dd Sratc LaNsrclalir8ro bui rirc rcpr6drarivd olrhis ( n, md ('ounlyto ml6 ulon the <br />abo\ e menlioned prop.rry lor ins <br />c-,t1-( 4I <br />DATE <br />T-Bar <br />Flood Zone Certif . <br />tonrratrorif <br />Lendd r Ad&-s <br />- <br />Apllic!tr|or Ag.trl Sig trltr.c <br />f-------T------ <br />tit