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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS ()9ncFBuild.r D.clararion I h.r.hy .mrD uods p.Mhy ol p.rrury thar l . .x.mfl lorn rhe c6nt do6' L'ens. h* for lh. followins roson G6 rol I 5 Rusincss lnd Profesion aodc) Any Cny or a.unry whi.h r.quir.s a pcm't locoBtrucl.ah.r. imprcv.. d.molish or r.pon any struc(u.. prior lo ns issurn....ko rcqlii6 rh. rrpli.lnr rorsuchp.mnro fil.osisncdsl fl. rh h.o!sh.nlic.B.d rucoanr ro rh. pftisioB or lhc conlGclors l-ice.s.d liw (Cnlprer e. ConrnEnc,ns *rh s.crion ?0o0 6lD,vis'on I olrh. aB'n.si rnd Pror6s'ons codc)or rhot h. or sht h cr.nrpl rh...noh aDd rh. brsir lor $..U.B.d.,.mprio..Any ri6hlio. ots..lidn ?011.5 hy aoy aprliclnl for a p.mil sutj.ctsrh. epli.rnr ro a.ivil t.@hy orn6r mor. rh!. firc hundr.d dollau (S500) l-6 osn.roithe prop.ny.o.my cmploy*s wirh !,s.s rerlrirk .c6hp.ns3tion. $illdo lt.$ori iod rhcatrucrur. h noi int.nd.d orolT.r.dforsl.(Se7044,Bon.cs5a.dP.6f.!3DmCod.'lh.ContictoirL'c.ns.Lrwdo6notrmlyrosnowncrofrherrcp.ny *ho builds or nuprov.s ih.r.o., md who do.ssuchwork hime.lfo.hcs.lrorrh.oqh his or lr.r osn.mploycs. provid.drhd sucfi impro\.m.nG ar. .or inrcnd.d or of.rcd aor sal. Il hos.\.r, rh.build6gor imrror.n..r i sdH snhinonc yclrofconpl.tion. rh. ()$n..Bd,ld.r aillh.!. rh. burd.n offoving rhlt lr or sh. not build or irprov. for thc purlok ofsrlc). l. is oan.rollh. prop.ny. an.r.luiir.ly co.rBclins wnn lic.N.d conractoE ro coGlrucl lh. prcjd ( S.c 1044, Blsin6s rnd Pmf.ssion Cod. The Contrdor s L'c.E. tl* do6 @r lpply ro .n oMs of propdy who bu 'lds .r mprov6 rh.r6n , rnd *ho contacrsforsuch proj.cs wih a c ontlcro( s ) nc..sed puBunt roth.conrE.tols L@ns. rrq ) ''4:l+.B & PC nr rhi! E6on Y"l0 NoRKI,:RS (I)NIPf NSAI'ION DI':('LANA'I'ION I l'.'.n) nln'n, trn u ,{nllr).f |tlu'yoncolrhc Inlki n! d..LIdilrns I tav.lnd sillnEi.iain aC.dific.r.ofConscnr to S.lr-lBU,e lor woikeB comr.nst'on,as prov'd.d lor ty S*r'on n700olrhe l,borCodc.lorthc p.donnanc.ofth.qo for which ih. D.nnn n ilsu.d I h.!.rnd wrllnra'nra'n work.rc conlPeNtron 'nstrmnc€. as r.qurcd byS.c!o. rT0ooarhe Lb.r Code. aorrlrpc ornunc.orrh. work for wh'chrhr pcrnni 6 issx.d My work.E comp.nsalon rnsurancccatri.r md poli.y numb6 m.: Polic, Nuob.r:__ErptB: (Thi! s.ciio. n .d.ot bc.ohpla.d irrh.pmir is for On. hundrcd dolliE lSl00l or lcs) I c.riifylh.l inlh.p.rformnc.ofth. work fo. *hi.h rhis p.rnir ii i$u.d.l rhrll ool dployanyp.6on iorny mlnncrsoaslo b m. bldlorh.wort.R conrpensdion lrws 6rC,l'ldri,r. lid lsre rh.r ill should b.com.subj.cl totheworkgs .ooP.Balio. provitio# ol Sdion I700 of rh. L3bor Cod( I sh.ll. aonhwith conply wilh thos. pmvhioN . /,^,"\o.q r4 WARNINC Ia'lur.lo s6ur. work.6 compensarrc covera-!. is unllwful..nd sh!llsubl(r an.nrloyerro crimin.l!.nalri.s lnd civil fincs up lo onc hundr.d lhousand doll.s ($10o.000).in rddnion to th. con oacomp.nsrtion, dams!.s as providcd lo.lhc Srrion 1076 of rhe l,hor Cod.. rr.16l.nd ltrorney s le* ueslsEDllll&lcruxslEc!^BAll!)! I hc,cby afinn trndcr p.n0lry ofp.rjury thrt I tun lic.nrd undd rovGi.. orCnlpt.r9(cono.ncins wilh Scction ?000)olDivisiotr I oi rh. Busin.ssand Pror6sio.s Cod.. !(l my Iic.N. t in lullforc.and cr.cr ,c.trscN.je. b16 a7 t,^'" \o .4. .\ cqlllalclta!,.l[Nlltctcllc.Y I hd.by.mm undd pcuhy olpdjury thal lh.rc G ! coclruclion tndin3 !s..cy aor rh. pfrolm.c. otlh. worr rorwhich lhir pmil it iss!.d (S... :1097. Civ C.). l,.nd.rs Add.es APPLICAN'T'S Df, CLAIIA'ITON D.mlilion t.mils-Asbcslos Nolifi..lion Fcd.r.l R.8ul iom (Titl. 40. P.n 6) R.quir.d Lltt.i of Nolin.di.n lc.nilyrhar rhc fcd(al rqul.ttr.s r.s.rdin! isbd(r i.n.val ar. no' rrplicabl.to rhis proj.cl. rn'septlicatiorandstntcthar rhc,b.\€ inionnation is conecr lasretocomplyeirh allciry dnd(outy ond hcrcbyauthorn. rcpr6.ntaliv.sotlhn Cny atrd Counry lo cnl.r opon rh. *-,P.q.pl Set Backs Erection Pads UFER Ground SLAB Floor Subfloor/VenUlnsul Roof Sheathing Shear Wall Framing ln s u lation/E nergy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif FINAL Certificate of Occupancy Notes, Remarks, Etc M \WP51\P€rm l.lnspecton F nq lnspeclon Record do. 03 31 06 forms/Steel/Holdowns i