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BUILDING- INSPECTOR RECORD <br />SITE.WORK ID/SIG.COMMENTS OWNIiR AU!LDER D'L('ARATION <br />I hcreby aflinn unds pedly ol pqjury lh.l I m €xenp' iro'n rh. ('onlracrnu' L,..n\t L.\r lor rhc follo(ns r;'en (SS:.7011.5 <br />aBi.ss ad Profsion Cod.) Any City o, Counly \fiich r.qut6 a p<oit lo consrrucl, ahq. improvq ddnolish or tQairey <br />$uclue. prior to ils isuecc. .lso requne thc appli.d aor su.h Frn b tile . siBned srarendt lhat h. or sh. G licoscd pursuant <br />ro lhc p,ovisios ofth{ conlractoir Lic.ns€d ll* (Chap.r 9, Con6c6ci.g snh sdrion 7000 of Dilisio.I ofrh€ Busins md <br />Pruf€ssions Codc) orlhat h€ orshe is excmpl tb6.tro d tlE hsis lor $e all+ed eroprion An,violaiionotstrtbn70-11 5bya.y <br />aptlicant for apnn subjccrsrh€ applicant ro scivilp€naltyolnot rolcthd filc hundftar dollds 1$50!). <br />I. c o\Td ofrhe poleny. or my cmployG rvilh Nas6 6rhen sE composarion. rill do lhc *o.I ddlhl slulde i! n r <br />i.bdal or oIT6.d aor sL (Sd 7044, Busind &d Prcfsiod Cod.: Th. C'ont.crols LicN Las do6 nor .pply to an own€r ol <br />thc pNpoly sho toilds or imrrcv6 lh@r ud who do6 sch sorl hms.lfor hdsclfor rhrouEh hh or hd own dnployc6. <br />providcn rh.r su.h i pmvmdk m nor ifldd.d or oftdqj nr eb I I ho$ a c, $. hiildinS or imp6\ ondr is sld wnhin onc yw <br />oaconDletiotr. rhc Ovner Buildo will h.\c thc hnda oapo\ inu lhd h. or slE did mt hoild or improve the pmpqry lor lhc purD(E ol <br />l. acoNndoarhc For,jdy, d d.lGively .o.tacrin! *ilh lioo*d Nfuadoulo..Ntud th. Fo.jd (Scc 7044.Itusins <br />dd hrfessir aod.: Thc Conrra.lois Lic€nsc LaN do6 not.ptly ro an osnd o I propcny Nho builds or nnprov6lhtr@n. <br />dd who conrEcrs for such prcjers silh a Contrrcron, licqs€d puGuanr ro rh. contactn's Licft. lr*J. <br />I n e\cmpl lnd.rs.rl,on .ll & l'( nn lhi\r$son <br />D.l.: Orn6: <br />woRr(.risicoirrpisaaloN <br />D[CtA8Arla! <br />I hdeby altmn u.dc. pdalr, oapajrt on ollhc follo$in! dcldarioN: <br />I n.!c d will m,int0io a Cdificare of CoBol ro S.lf-lEure for uork.6 conipens ion, 6 prcvid.d fo! by S(tion :1700 o r lhc <br />tibor ('ode, for th. FaomMc. o f (h. <br />"od lor $hi.h rh. rmnn il Gsued <br />I harc and Nill mainlaio wo,kerr coNp.Nlion nsuranc.. a requtal by Sar ion 1700 of lhe ljbo! Cod.. for lhc p6fomdc. or <br />Nl!itruran c.aid xi p.licy numb6 ! e: <br />OD <br />I ceniry lhal h lhc pefonn.nce ofihc trort lor $hich nris fsnrii is issued. I shaU n.r employ n.y psson in any mdn.cr <br />s) irs t) hcc.'nc s,bjccr i. rhcu.*ds corpcnsrion la\s or( aliromr. afti,uN thir ill sh.ul{l r$o'nc srbie.r ro lh. <br />$0116 emp.nsdn n polttuns ol Sd on I700 of rhc l-a&tr Codq I sh ll. l'onh\rirh.o pl! lvir[ rho* p$isions <br />lo lacu€ \!rk6' comD€osariotr covmge is unlawful. ud <br />rh.LsdJ dollrs ($100.000). <br />'n lddirnn !, rhc <br />inr.rci a d ortr! s Lsx <br />I h.r eb! atlth unnd pdahy of lErjury lhit I m licensal lndd pmvision o e I (connrcncirs \ ilh Sdion 7(100) oaDivrur l <br />ol thc Busine &d Pbfd\ioN Cod.. md n, li..nsc i1 in lull for.. dd .lTcr <br />/ <br />CAIiIaI]CIIONJ.INIINC.AC.ENq <br />I hdcby ainlm xndd p€rally of pdju.y that lhqc is a cododion loding asency for lh€ pstonnocc ol thc work lot which lh6 Fsil is <br />iss!.d (Se.1097. Civ C ) <br />AIIITIANLDECIAAAIIA! <br />I h.rtt, aIImu.do pcnahy olpdjury on ofthe followi.r ddl&arionr: <br />D.nolrtu. Po s^sb6ros Noriricdlion F.d6al R.sularions (Inb 40. Pan6) <br />R.qnted Ldrd olNo ncdrion <br />-r <br />cel ify r har the aedsal r+rnalions reBedin3 sb€ros lLrnoval are mt applicabl€ lo rhs prorecl <br />I cdify rhat I nave ud lhis ap icar <br />odinanc6 &d Starc lrwsrelatinr lo bu <br />abvc nrnrioncd propcny for inspdlion <br />I a,gre lo .omply $ irh .ll Cir, <br />Appli{itrl or Agenl Signrturc <br />l'(Dilrc utrc (prnrl): * <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsulation <br />f,.oof Sheathing <br />Shear Wall <br />Framing <br />ln su latio n/E nergy <br />Drywall <br />Ext./lnt. Lath <br />lvlasonry <br />Pool Fence <br />T-Bar <br />tlandicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif . <br />FINAL ulv>lN'i '4) ) <br />Certificate of Occu -I <br />rtr lpancy <br />Notes, Remarks, Etc. <br />.t <br />DATE <br />Brown Coat <br />L <br />LcnJcis Addrs <br />--f------