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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE OWNIiR I}I] I LDER DELCA'L{TION <br />I h6.by amm undcr p€nahy ol pdjury thd I d qcmpl freto rhc Cont,.lon' Licerp Law ior rh. folloqinS rwn (Ss.7011.5 <br />Busir6s and Profdion Code)r Any Cny or Co!.ty *hicl r.qun6 a lsnil ro comrtucl. alls. inlProve donolish or apat &y <br />shduc. prior ro ns isue.c. also requir6 d. appli.er for soch Fflrn lo filc a sisncd statm$l lhal h. or 3hc is licm.d tBuei <br />ro rh. rrovirioE oilh. Conrado.s Licnsd lls {Chaprd 9, Conn.n.in! wth Sdion 7000 ol Dilision I ol rh. Bsi..s dd <br />Profsions Codc) or th.r h. or shc is cr€'npt rh6.Eom lnd rhc &6is lor th. all.red crdprioo Any violalio. ofs&1io.70ll s bya, <br />applica ro. a psrnn subj.ds rh. applicdr ro a cilil dahy ol nor 60r. $m 6r hun&cd dolltrs ($500). <br />l. s oNn6 oathc prop€.ly. or my €mplo)6 wilh was6 6 lheir $lc co pdaion. *ill do thc so,[ ad ln eddrc i! ml <br />inrqdcd or o,te.ed lor slc (Sc.704,1. BBinB ed Ptut6sions Codc Th. Conlriclol s Lico$ tjw dod not apply lo d os6 of <br />rtc pmF y trho boilde or imp.ov6 th6oq o.d who d(E sucn No.t,rirs.lto' h*lr or lhrou8h his o.h6os cmploye. <br />proriid rh.r soch imrnovmB @.or i,t6ld.d oroltod aor eL.Ii ho$o."s. tlE hrildins o, inlproYdd i! $ld sithin on. rd <br />ofcoq,Lrion. rh. OMo Buildd will harc ih. hndd of povng rhat hc or sh. did not tdild or imFov. thc p(opqty for thc purpos of <br />l. 6 otr n6 ollhc Drcpdr, m .xclusiv.ly contEcr ins vith licc6.d co.rracrou ro codru!-r rh. projd (s(. 704.4. B6ins <br />and ftoisbn Codq Th. Conlflcror's Li..6. Law do6 .or atply to e osn6 oaproFny trho builds or improv6 rhdon. <br />and vto conlra.ls for such Irojels wirh a Conr6clo(s) licd.d pu6@l ro lhc Co.lEclols LicN ks). <br />la cxenrpl undd Scrnnr ,li. & l'.C. tuthr r6on <br />]lgAKlrEggDUENlAllOrDE(!A&!llQ! <br />I hcreby aman undcr pcn0h! ofpsjuryoncoith. aolloslnE dela.alions: <br />I hav.adNillMi sinaCdificareo|Cons ro S€lal6u,e tor rvo'k.d cdnrpen$rion,6 Fovid.d for b, Sdion ]700 oflhc <br />I4oi Cod., tor rhc pefor:M.e of lhe qorh for whicn tht pmnil is issued <br />I havcand Nillmaintain *!lke.t conrpensation i 6 requned by s(rioi 1700 oi r h. Ijbor (nd., for the psfonnancc of <br />lhe wo aor which lhls pmril is isnred. My worked n inntrnNc rmir mJ l{,ln, ru. cr 4,. <br />-I <br />c.diiythar i.lhcpdfoi,nMc.ofth.Bork for s'hich lhis !trmit is issucd.l shall nol oaloy any pdson in dymmn6 <br />e s lo beome subj€l lo lhc NrL6' comFsslion la$ olcalilomia, dd are Oal ia l 3horld bdo,n subjd Io thc <br />porlm compwlion poviei.N ols€clioa ll?00 oi th. ljbor Cod.. I shdl. fonh* nh conpl, {ith rhoF l,ovasions. <br />WARNING Failure ro su. work6' conp.rodion covda8. is unlaNtul. md shall subjd d 6plo,6 to dimin l pduhie md <br />civil nn6 up ro or. nudr.d t <br />Sdion 1076olth€ bbor Code <br />,.,". \l[-20-( <br />00,Ju0r. rn add .on ro rhf.nn r (qnp.nqr'o.. danarB a pro\'ded ror rh.2 f2t'bul" mrv <br />IIOXSEDTOTINASOB <br />lniclJ8a:ItoN <br />I hd.b, allm undd p.nrh, olpdjury lhal I m licss.d und6 ,rovision olchlprg 9 (.od'n .cins with sario.7000) oIDivision l <br />oa rhc BGin6s md Profasio6 cod.. ed my licmc is in ltll lorce ond .ilect <br />9 AcA <br />^,, ) | ^ )A:--l Lcon*.o.E () <br />o 7 <br />I h.cb, afiirm undd Fnahy oI psjury lhal rhqe is a mnsruclion k dins as6.y for inc pafomecc of th. *ork tor snich lhie ponit ; <br />issled (sd. 1097, Civ. c ). <br />AITLICANLDIC!6AAUA! <br />I nor4.Irm lndr paalty ofpgjuryonc oflhc fouowinr d(larationsl <br />D.,nolirion Pmts-Asb6tos Norincalion F.ddal R€gulations (Till. 40. Pan6) <br />Rqu;q] Laln ol Notifi.dion <br />-l <br />c6ti ry rnar thc icddal r.rulalioE csedins 6b6ros r@oval rc nor applicabl€ to rhG pmld. <br /><i(Inr,n, , **."0 <br />'nis <br />0pplicarion md sar.rhar rhc.bvc inronnariotr iscor.cr.I arre ro conpry $irh .rr ciry and counry <br />ordilan.6 ed St.rc bwc elatin8 lo building coanruction. drd hseby aulhoriz. r.F.$rdiv6 oalhis Cn, ed Counlylo (ls upoo lh. <br />,\pplicatrt or Bort Sianrli o-({ <br />Perfl itec nrnm (prinr): !< <br />t?tt <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsulation <br />Roof Sheathinq <br />Shear Wall <br />Framinq I 7 t{v.wil <br />lnsulation/Energy <br />Drywall I <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar t \,v-w <br />Handicap Req L <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL 5"1 "l )-"Fl-r( <br />Certificate of Occupancy " r17 <br />Notes, Remarks, Etc. <br />ID/SIG.COMMENTS <br />I <br />-K-17Ext./lnt. Lath <br />t)) <br />Policy Nudbd:LErpn6: <br />lXhvt-(atrltx <br />n4no