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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUlnsulation :\ <br />Roof Sheathing I - I'i -r Y Y-)Utc)N-atut1 d.PT' <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coal <br />N/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif . <br />,/\ <br />FINAL -?l-lt tx.\4.74t <br />Certificate of Occupancy IJ <br />Notes, Rqmarks, Etc <br />J P ,5 ?6tQb )4t'v0 I <br />OWNER BUILDIiR DDI.(AR TION <br />I hoeb, amrm lnder p.Mlry of psjury liat t m cxempl 6om th. Cont6.ro6' Liccnse rjq aor lh€ iollowins ,een (S.c 70.11.5 <br />Businss md Prolsion Codc) Any City or Counly lvhich .equird . Ftnir to cod d, ahs. imprcve ddnolish or mtan ry <br />slruciure p.i)r lo irs isu cc. d$ r.qui6 tbc alpli.dt for such pdni o lile o siSncd statmot lha hc or s1,e is licds.d puBanl <br />b rhc provisiom ofrh€ Cootacrof! Lic. ed l** (Chaprcr !, Connncn.ing Nith Seiion 7000 or Division.r olrh€ BusinN md <br />Prcfsions Cod€) or tha! hc or sh. is .r.opl thddrom trd th. bsis lor the aucs€d .rdpridn. Any violaio. ol Salnrn 70.1 I 5 by any <br />aptlicnm for a pmit subjats lhc arplicanl lo a cilil p€nally o f nol tooa rhd li!€ buftlred dollds ($5001. <br />-1. <br />s osnd 6arhe pror6rr. or my .mplo)€6 $nh *as6 6 thet $lc codpis{ion. will d. th. \ ork ed lh. nrucl@ i! ot <br />i dril or ol'd.d aor sle (Sc.?044. Busin6s .nd Proisions Cod. Thc Conlraclols Licre tiw do6 nol apply to d o"id ol <br />lhc prcpq1y who hril& or improv6 thqon, od who do6 such s& hnns.lf o! h*lf orlhmush his orhdoM anPloyc. <br />prolidal rhd soch inprovdft.ls a. nol hr6do.l o. olfc.d aor sL. Ii howd6. thc hlildins o, nn tottl@r b $ld wnhin ore tq <br />olco:npldiotr thcOMr BuiI:16eill hav.llEhtrd6 ofpro rB rtd h.orshedidnol trild or L.prcE tfi. rxlrdy lor fi. purpokof <br />I. 6 omd oithc l,oFny, dn€xclusiv€lyconrracrins Nirh liccNd ooitadoN lo co6lrud Ihe prejccl {Sd.7o4t. aci,ts <br />a.d hoktion Codc: Tn.conlrrcl.ls Li..n. Law do6 nol q,plrlo m own6 ofpropsly who buildr or isprov* ihssn. <br />and sho oirraft am sichpmj6G *irh a Conrraclo(s) Iicscd puGudr rorh. Conlractois Licffi L.!v) <br />I arr c\emfl undcr sdion . ll & l'C turilris rutson <br />llaBtrEls:l;ou8llrarraN <br />PECITAEAITO! <br />I hdcby am,,n u.dd p6ahy ol Fjury onc oflhc folloNins ddlddioal <br />I hsv.tu \villmai.rainoCcniarcalcolConsnttoSclf-lnsur.lor*olk6s'conrp.nsation,spmvid.dio,bysdrionlT00ofthc <br />Labor Code lor lhc pdfommcc of lhc wort lor \iich lhc Fnit G isucd <br />I have and Nill marrE,n woikerJ compeB io. iNordc., 6 rcquted by S€cl ion l70o of th. I-.60r Codc. lor lhc Ffomdc. ol <br />rhc vork ror shich rhi! Fftn is i$.d Mt workgs comp.ns.tion insudcc cuid ard Fli.y nrmb6 tucl <br />Policy Nunb6: EiPi.6' <br />-l <br />cfiifrrh i6 rhe pdaorsancc ofthe vork tor shich rhis Fmit is Lssuql.Ishsllnor dnploy.ny pcBon in uyndnf <br />e 6 ro be€omc subjst to rhc ro'k6' cofrr.Mrion lass oacaliaomi.. ..d asre lhal if I should b.ion su6t(r ro <br />'hewoldm' mnrpqsal rc. provtio.s of Seli.n 1700 ol rhc Labor Code I shall. fo.lhrynh o'nply wi(h rhos Pmvisions <br />WARNINC FailuE ro surc wort6' comp.Balion co\ms€ is unlastuL ad shall srbjdl loler nr li'ni'ral Nrlri.: nnd <br />d {acs ns pnridcd ld rh.civil fi.cs up lo onc h@drei rnousd dollm ($100.000), itr .ddnion Io lhe cGl of <br />srri 1016.rrh. L,rff(.n. inrtrnt ind <br />{*"I hcEby amrm undq p€,all, or $rjury rhar dn li.ctu n indd pmvirion ofch.pr6 I ( <br />ol rne Busins Md Proa6n'6 Codc, ud ny lic€Nc 6 in full roftc and .ll(r <br />I h@by arfm u.d6 pe@ny o f pdju.y lhd <br />issuai (Str. 1097, Civ. C ) <br />is a coBtoctio! l€ndins aBo.y ior rhc lsfonnmce ollnc vort for shi.h thb Frnil b <br />Altu(ArfD[ct altAuo! <br />I ho!t, afinn undd ,enalry of pdjury o.. ol rhe folloqin8 dEldalioos <br />Dcnolnion P.mneAsberos Notifi.arion Fcdd.l ReSularions (Ttl€ 40, l'a16) <br />-Rquncd <br />Lclr6 oi Nor6.aio. <br />-l <br />cdirylhal the tedEal resulalioN Egtudins sbsros dn.!.|tre noi arplicablc to lhh pmr.d. <br />inlnnn.riotriscotrd Iagrelocontpl,snhallCittmd(-ounly <br />axrho.ize le!!*dsrn6olthis cny ed counrylo dt6 upon lhe <br />( <br />/?/8 <br />Set Backs <br />Shear Wall <br />L.ndd i Addr*: <br />I <br />--------r------I