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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS O\!NER BUILDEN DELCARAl'ION
<br />I h€reb! amnn undd pcnalty ol pdlury rh.r I m.xc6pl Foi rh. Co.r,adoR Lictrc l-aN for thc lollowios Een (Scc7011.5
<br />Bus.6s qnj Prof*ion Code) Any City or Counly which reluts a p6nit ro coNrtuct. ah6, imptuve, danolish or Epair dy
<br />snlctue priorb ns isrum.e. al$ r.qun6 rhc applicMr fo! such F6mir io lilc a sisnen iat€mflt thar lE or she is licd&d pusutrl
<br />ro rhe poviiiont of tu Contracloas l-icds.d L.r (Ch.ple 9. Comh.nci.A lnh Se'ion 7000 of Diliiion I oarh. BBin* and
<br />,'rcfNions cod.) or rhd h. or sh. is .r.mpr rh6cEon d rhc basis lor rhc all€sed eGnption Anyviol0tionoisdion7011.5byany
<br />{rr'\0d loripmnsub'd\rhc dppha rodcrv' r.nJk) "l.ur mr'.,ld n.c hundr.Jdclldsrlt00,
<br />r'll,L1a:l;I, is u(n.r or rhc propeny. or m) crnplnlc r irh oag6 a th.t $1. .onrprelion. \vill tlo th. $orl ud t mdE i! nol
<br />inird€d or olfd.d f.r el. (se 7044, B*i.ar &d llrofNions Codcr I hc Contraclois Licm La$ &16 nor .pply lo M o$ns ot
<br />rhc pbpeny \$o builds or iqr.v6 rh@r ad who do6 scn $i( hims.lf or hds.lf.r rhrotrgh hk or hd om mplotc.
<br />providcd rnal such impro\ondts e not imdded o. oll.rd for s.]. I f. how.vE rh. bildiry or improvdnol is sld wirhir onc y@
<br />ofconplclion. lnc (\,nd Builda will h0!. the htrdd olFovitrs lhal h. or shc did lot h,ild or i'nprove the pmpsly aor lhc pulros ol
<br />l, {s o\T( ofrhc pmrmy. u .xclusivcly conrdints \nh $cdr*d ..nra.roN ro .onsnr'
<br />'h.
<br />p6jd (Ss 701,1. &r'n6
<br />and Pioldion c.d.: Th. co.r€croas t,icd.. LaN do6 not.pplylo anorno ofp.orEny sho builds o! nnprovB thod,n.and rho .oilracts lor such poj*ls qith 0 Contado(, li.Nd puBoanr to rhc ConiB.ro Li.ds LaN).
<br />I tuncxcdpt undrS.crion
<br />"X u/zzpor .Lr &f ( i!1lMosur.
<br />""Y //J- ttl-,o,-/' sfrur:s'rrxrlrnstfrti(
<br />OC(IABATA!
<br />I hocbJ, amni uflrlLy poaxr- olpdjuryonc ottne rollo*ins dccltualionsl
<br />I n.!c dd \yill
<br />'nai.rain 6 Cdlincerc olcoMr to S.lf-lBUre ao, s ork6 .o,nposlion. s Pro! ideJ aor by Sdion 1700 ol rhe
<br />t,bor Codc lor lhc pgtomece o llhc \ort lor shich rhc pdnh is irsuql
<br />lhrvc.nd $illnlai nn work6 .o'npc6axon insulancc. 6 reqtriredblSdionlT00oftheLabor(tdc.lorlhep6formnceof
<br />ihe Mrk ror$hichlhisp{ml G issu.rl. My workes' conrpqsatiofl insuruce snis.trd policy numbs Ee
<br />Caricr:
<br />(f1.o,'4,r'a,rr,.p-r,rm..orrhctr.rkrnrs.hichihispflnlisrsucd.Ishollnoldproyanyp.reonrnanynann6
<br />e 6 kr b€.ome subJdt lo
<br />'hc
<br />Rolte co,npsMion lass ofc,lif6m,a, dd asre rhd il I lhould b.$n. .ubj(t lo lh.
<br />$r(c compeGalion prorisioN oasdlion T00 of (h. bbor codq l slsll, fodhwirh.onply { ith rlk'e povilioN
<br />\TARNING: Failur. o ecu. s..l(m' compqsrnJn cordse it unlatr rul. ed shall subjd oplo]s to aininal pouhi6 ud
<br />civil lincs trp to one hundrcd lhoosmd dollm ($100,000), ii addnion io lhe cosr or crD!€oetion. d@as€s d provid€d ror th€
<br />(odc. i(er€st a.J axornlrt Lrs
<br />//7d1
<br />r r(l:\\til)( ()\rRl( toR
<br />DFCLARATI()N
<br />I hmby .mrm ullc6 p..rhv oa pdjury rh.r I d licns.d und6 proriion oi ClDpr6 I tumocios v h S.dion 7000) ol Division l
<br />oa rh. BBin* ed PDl*ions Codc, ud my lice6. is in tull force md €fld
<br />( o r.c(or
<br />CO!$AUC TOT-IETOIIG-AEEIII
<br />I hqchy.alim und6 pe.ahy ol prjury ihar thd. is r.oslndnn k di.g !udc) hr rh.peaomdce otlhc wort lor \rhich lhB FDit is
<br />iso.d (S(.1097, civ. (.)
<br />APPLI'AN'T DECI ARA I ION
<br />I hod,y afim undd peahy of Frjur) o.eotthe fouoying declaBtions
<br />D€'nolilion Pmils-Asbcslos Nolificalion tcddal R.grldions (Tnk 40. Pd16)
<br />R.qut€d t..1rq ol Noliliation
<br />I c.niay thar rh. l'.d.61 i.luhrio rcsdding rsbsk's rcmo\ al ae rcr applicable 10 rht projecl.
<br />tC4-,'ry tr,r tt ^,,*arr,rs spplrar'on md srarcrhd rh..t{!. inro,rnaron is conecr l.grdrocor.plyrvirhrll(ny0nd(tuniy-i.i/mtic6 d Skk I i{ s rclnunA ro bu ldmS coErtud i.n. exl fitr b, aulho.ize rcPr6ard i\€ o f lhis (iir} ed colniy ro dra Wo! th!
<br />ab.\e m.nr.n.d t6FF) f.' iBrdli.n pqIF s6 /
<br />,rDpricrnr or.rcm,sknrrV 4*-/? 4r..-
<br />r",n,rr*n","rp,trd, 2Lru<:at z l6u6t / ty'=/'*r
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Roof Sheathing
<br />Shear Wall
<br />Framrng 7/nVz)ECZ 1
<br />lnsu lation/Energy
<br />Dryvvall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL 7/z*,/ea KZfir^tezzsSD
<br />Certificate of Occu p"icyT
<br />Notes Remarks, Etc
<br />\
<br />UFER Ground
<br />Subf loor/VenUlnsulation
<br />T-Bar
<br />Flood Zone Certif.
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