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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE COMMENTS <br />Set Backs 'f <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation <br />V.tmsa<Roof Sheathinq 1/2nq1 r-y9) <br />Shear Wall lt <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 Final Report <br />Flood Zone Certif <br />L. <br />nCertificateOccu <br />Notes, Remarks, Etc. <br />OWNER BUILDTJR DEI,CAIIATION <br />I hs.!y afrtrn undd poahy or psjury lbot I m €xenpt liom rhc Cont.cton License Law lor the follovin8 rlen (Se 70]I t <br />Itusins and Prol6ion Cod€): Any C y or Couoly *hi.h r.{lund . pdnir lo .onitucl. ah6. inprore, r(molGh .r rpan m, <br />srruclue rF ro irs issuece, aLo r.quic rh. applic&t for su(h Fflnit Io filc a sisncd slardor rhd ne or sh€ i, lic€.s.d pu6u&t <br />ro th. pmvisions ot th. Conr.acro.! Li.ens.d Ls (Chapr( 9. (i,ftmcn.ing vnh S(rion ?000 ol Division I oath. ausincs ed <br />PDacssions Codc) or lhal b. or shc 6 crmpr rhrc.rom sd rh. b6i. rot rhc allets.d cxmprion. Any liolarion of Sclion 703 I i b) ant <br />appli.a aor6p.nnsubjd8tne.ppticmlloacivilpcnaltyotnol'norcrba.fiv.hrndr.ddolles($500) <br />l, 6 osrd oflh. p.orEiy, or my .mplorc with $ as6 6 rh.n $t &npoDri6n. siu do ln. wolt dd lh€ nDdE u nol <br />inrdded or o fid.d lor sL (Se.7044. Bsins dd Ptol6iotr5 cod.: The (onlracloir Licdsc L,w do6 .ol a?pl, r. m ownd ol <br />therlpq1y $ho b{il& or nnprorB lnaon. dd *ho do6 sch Nrt hims.lf or h6.lfor rhouSh his or hE oqr oployc, <br />piovid.d rhar su.h impmlodB e rcl inldd€d or oflbld ror elc ll ho{cG. $c toilding or inFov.|Mt ir et wnhin onc ya <br />ofconrphnrn. Oe O*n6 Buldd $ill h,v. th. htrd6 ot provins $d hc or sfi. did @r blild or nntrorc the popqly for lhc ,urpo$ oa <br />-1, <br />aqownoofrh. prcpdr, dn cxclusivcly conlrdins vilh lics.d conl'acrouro coNtud lh. Eojccl (Sd 7044, BBms <br />.nd ltrLssion Cod€r Th€ contrc(or's Lic6s. Lr* do6 nor.pply to an osocr o f prop.ny *ho builds or nnprows lha@n. <br />tud *ho co 6cts for such prcje.ls with a Contrado(s) li.m.rt plBud ro lhc Conk.clors Lictuc L.w). <br />I Nc\c rln uNl.rs.crion .ll & l'( ln' rhs rdrnlr <br />l!.qlEDBll(lllltI!,laf!!)r <br />Df(]LARATION <br />I h€rcby trmrm under pcoalryorrErjuryon.oarhc aollos,ins Ll(tddioN: <br />-l <br />harc and wiu tui aln a Cdificale ot Cocar to S.lf- INU'. for $ork.B' conrp.nsrion. as provi&d lor by S<tion 1700 of th. <br />t bor Code tor lh. Fforfucc of tt. $ott fot wtich th. pdmn n is!.d. <br />-l <br />hav. and will nai.tai. wort.rs compffdiof, iNuranc.. 6 ralutcd by Sdtio. 1700 ollh€ L.bor Cod.. for lh. Faonmcc oa <br />rh. $rk for shich thi! pdnn G is.d My uorkm comp.asalion iNur&c. .did 3d policy numbs uc: <br />I ( A l,1l c0. <br />U A-t.;ol SO I -o I - l!l <br />-! <br />.dirt lnar in lh. Faormancc ollh€ rort lor whi.h lhis p.flnn i issucd. I shall nol 4ploy oy p.Mn in &Y mannd <br />s 6ro b€conE suqid to thc rort6 conp.Brtion la\s olcalitomi4 dd.r@ tha' ifl should bdomc subjdl to lh. <br />wortc'&mD.@rionrov6iomofSdionlT00otln.LaborCod.,lslDll.aonh*nhcomPlywiththoEpmvisio6 <br />WARNING: Failre lo suc $orlc6 conpdsatnrn covd,g.,d to ainrinal poah6 &d <br />cilil lincs up ro onc hun&€d lho@d doll4 (!100.000). h dmales 6 puided f$ lh. <br />S.crion 1076 olrfic Llbor Code. irGr &d altomcv s lB <br />It-2|' <br />I hercbyatfirnrunderr.oahyoapdjurylhd I n liccnsn prolision oiclEptd I (.om,n€ncins wilh Scclion ?000) olDivieio. l <br />oi IhcBusinsand trclsFnsCode, dd myli.m* is in full lorcc defid. <br />x,.," <br />C3 q l't a I \ 6<h <br />I l-zt-l?) <br />I hdby aron !nd6 Fn y of p.rjury th.l th@ is a onnrudon Endi.8 a86cy aor thc pqfolrwcc oalhc (ort for vhich lhis Fnn it <br />bsued(S(. 3097. Civ. C.) <br />AEITCANLDECI,AB{IIO! <br />I hort, an'm uids Falty oapdjury on. of th. folloqins d(ldol ions: <br />Dcmolition PamiB-Asb6t.s Nolificalion F.ddal Rcsrlarions fl nk 40.Ian6) <br />-RcquiEd <br />l.lldolNori'i..lio. <br />I cdlilyrnar the fcddal resulal ions rcsddiru asb*r$ rcmdlaldc n.l.pplicable lo rhis p'ojccr <br />I.oliay lhit I harc read lhis appl'cahon srarcrhar rhe abov. inr'onnation is cotrd.I asrclo.o,npl, wilt all Cilysnd Counl, <br />ordin.ncB aid stare kws relalirytobuild lsprsotariv6 olrhis Cny ed Counlylo enlq upon rhe <br />au,r e lEnhoncd p(peny ,or iBpdtioh <br />f^ppli.rn( or ABenl signllure:o,t ll'7/- /6 <br />C? ^a/ 1,, <br />\r'{nri(cc n.nrtpri'rr): <br />,vt <br />l! <br />T-Bar <br />F|NAL /r/Y//7 i <br />L.ndeirAd&6: <br />- <br />I <br />I