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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUII,'}EN DNT,('ARA'I'ION <br />I lrEr,r_ af,ir6 undcr Enalry ol peijury lh6r I @ crc'npr nom rhe ft.todos Licdsc LaN lo lh.lollo\vi.s r6son (s.c70ll5 <br />Busin6s and ProlNion cod.) An! (ity or comr) $hich reqtrtd a p..mi h codrucl. ahq, intror.. d&nolish or r.pnn ary <br />sttuctore, lI{). ro ns isudc€. .lso relun6 lhc applicam ior such pqnit ro fiI. a siln.d sl,h.trl thal h. or shc is licosd pusu.nl . <br />to rtu Dro\isiotu of rh. (o.ka.t.fs l-ic.B.d hrv ((-hafld 9, C.,nm.ncin! \ith S€lion 7000 of Division I oarh. BNin.s .nd <br />PNlssionsCod.)orth.rh.orshcis.r.'npr rh(.liom.nd IlrbNis lorrhcallescd erdpxon Any \mhrionoisdio. T0ll.5 b, any <br />.prlicanl forapmir subjslsrh. appli.a.tt' aciyilpenaliyornor mor.rhan li\c hundr€ddollaGlt50O). <br />I. .s oNrcr ollhc proFrly. or nrye,nplo)€6 vith N0s6 as lheir vnc conrplm.rin. $ill do fie trork md lhc sln'c1re s nor <br />inrfldql .ro,Tr.d for $lc(Sa.70,1,1, Bu$nds.nd ProrsnnB Cod. rh.(ontra.r.rsl-icase|i\rdo6norappl,roano\atoa <br />ln€rmpdry sho h,ildeor imn!!6 th.mn. d who do6 scn tro* htnsell o! hss€lr or rhoush his oi hd o$n .mpl.re6. <br />prcridolrh such ihpro!@nt d nor intnd.d oi ordln lDr sL. ll ho{ 6 (. rhc hriklin! or ihFovqml ii snd \ irhin on. }a <br />ofco'naldion. Ihe (n\ nq Buiud s ill hav. $. hrde ol rorinB rhd nc or shc did not t{ild or iDprc\ c thc prepsly ror rhc purPr oa <br />l. s.skrofth. propcn!.0mcxclusiv€lyconnacii,rs with licetrscd conrrrcro6r(' (isro.l rh. Irej.d (s( 704.1. RGinLs <br />and hoftsion Codc Thc Conlracrois l-iccnre l-aN do6 nol apply ro tu oN.s o f trupc v Nho builds or iDpro\ €s rh6sn. <br />and *ho.o.ricrstniuchpiojelswnha(-o.r6ckrdrliensc'lr[suanlrorh.Conr.aclor'.I-ictucLn$). <br />I dn ersnpr lndd sdlioo <br />]UOBEEgtiOrlrEllAltO!!!ic! tsdto! <br />I hdc$, amiin undd ps.h,oflsjuryon.ollhc aollN\ inr dNl..alions: <br />I nale .nd \rill ndnr0in a cd ific.re o I co6mr ro s€la-lnsure l{! * orkss co rpos nnr, as r.r id.n for by Sclion 1701r oflh. <br />L.hr cod.. for th. pdaonnmc. o f thc qod{ Io! which thc pmir n isued <br />lhar. and trillmai.rain \o ds'.onrFcnsartun instrr.n(...s rcqtrn.dbyS{lionl7O0ofrhltnhor(od..rortheldfonnan..oI <br />rhc sork for \rhich rhis pnnn is issu.J MysorlBs compeflsriotr iB aNe csFis and Erlicy nunb.r ec: <br />I celifyrld in rlrc p.rlomance oflhc Nort for shich lhis fdil is,s$td. I shall.or mploy any rsson in any nrannq <br />s. trs b b.co6c s'bj(l kJ rhe Nol{6' c.mpsB.rion laNs ol'calitomi.. ind is,E lhar ir I should b<om subjd to thc <br />\$rkds romtnsrrioifiolisn)nsolsd..ri.n]700olrltLalatr(odc.ls)mll.lonh$ilhco'n <br />NARNIN(; Iiailoe 10 se.rc $o.k(l..n,pmsar(n, ..\.ras.s trnla\lL'. and sl[ll nr itr flnflo).r tu si i',rll{lrxln nxi <br />cnil 6nes up ro ooe hund'.d rhousdd dollas ($100.000), ii adJn p€nelion. ddnas.s a F ovid.d for dr <br />Scrion:1076 ofihcllborCod., inra6r dd ddn.! s LB <br />DECLAAAIIQT <br />I t@by.m!n uod( pqalty of prjury Ihal , so lice.kn uidd pm!hi.. of(-h.pr6'r {commocins rvilh S<rion 7000, oionision 1 <br />:".:::":** <br />**-" * * ^ -* " ",:._::_i <br />Da'e ^**,vkw- <br />co!$trllcrolrlllllNc-dclrcl <br />I h6.by amm u.dr pcn.lry o f pdjury rhat rhd. is a coNodion l.nding asocy tur th. pdaomdcc oarh. sorl for which lhis pqni b <br />issu.d ts(. l097. cir. c ). <br />APPI ICAN'T DE(:L,{RATION <br />I hqt+ry alrn. und( pdahy ofrcrjuiy.n.olth. follo$in! d.cltr.lio.s <br />D€,rolilion Ponirs-Asb6tos Norifi cdtun Fedddl Rcsuhrnru ('rnE 40. Pan6) <br />Requned Lcu.r olNorifi carrcn <br />I cdrili rld rhc fLlt\i '.a0L ior rc!aRlift islrn.ir.nr\'rl d Dol xf!l'r3t)l.t, rlris pr\i( <br />I.cnit thar I ha\e rsd rhis ar0licarion dd sr.r. r inlonndion is cord I asrcro.orply(irtrllCnr and Cotrnr! <br />ordi.ancs and Srarc !nss relalins lo 6uildin! o hmb! aorhor tc reo €sdalivd ofr his Ciry i.d aou t ro orr upon rhc <br />.'lx,\( nr0rkrrr f'o|tn! lil <br />,,",.,L - /0-/ q <br />.\t,t,lirnnr or \sc r Six rru,u <br />lunilN nnm. (p'n():ttr, <br />^nrali^DL' <br />Set Backs <br />Forms/Sleel/Holdowns <br />Erection Pads <br />UFER Ground <br />Subfloor/VenVlnsulation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />ln s u lation/E nergy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Ivlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL 2-ztkxq zJdA 'ldyv) <br />Certificate of Occupancy <br />Notes, Remarks, Etc <br />l)itc: <br />SLAB Floor