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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG,COMMENTS OWNET I}UI I-DER DI]I,CAIIA'TtON <br />I hreby amm und6 pcnahy ol psjury Iha I tun demfl 6om lhc ContractoE License l-.s lo! the fouoNinr twn (Se 70r l 5 <br />Busines md Prof6ion Codc): ny cn, o. Counry shrh r<und d Fmi' to connrucl .ltd nrprovc. dlnolbh or EPat Mv <br />sttudurc. p.ior ro ns i.suec., also rcquts lh€ arplicer tu su.h P.nnn lo filc a sisn.d satmmt lhd nc or sh. b licdscd p6udr <br />ro rh. rolisiom ol ttc Conlncblr l-icenkd L3w (Ch.plcr s. Codmencins wilfi S(xon 7000 of Llivision 3 oath' Btrsin'{c d <br />PrDl€sions Codc) or lh hc orsh. is.rcmo rh6€flon d rhc bsis lor thc all€s.d qanprion A.v viohlnrn oisdtion 7011.5 bvanv <br />applicanr ru d p.mn su6jdslhe arrplicanl lo a.ivilp€nalrrofnot,notethd lir. hundr€d doll4l$50o) <br />-1. <br />N osn.r oilh.PIopcny,.i my.nPloy€6 wirh was* 6 rhct slc comp.6atio( rill do lh€ No,k dd lh. srrudu. is ml <br />inro& or of€rcd fo; et {Sa.?O,l.i, tJusins &d ProlsbB Cod€ l lc coniractol s ticmc liN do6 nol tpplv ro M ownd ol <br />lh. pop.ny who huilds or improv6 rhdn. md who do6such {6rk hnns.lfor hqElforrhbush his or hq oM.mplov€6. <br />providcd rh such ihprovdEnls oc nor inrdd.d or ofd.d tor ek. l( hous6. rh. hikli.s or i'qto\!m.r is $ld vilhin on. ,@ <br />;f corpl€iion. rh. O\us Blildg u ill havc rhc tdt n ofprovin-! lhd fic or 5h. did nor 6ild o! nnFov. th. p,lpsrv lor lh. purpos ol <br />-1. <br />s ownd oarheprcr€ny. dc{lGivclycontraclins Nilh licded contadoN to co.srtu.t rh. F{oie<l (S€. 7044. Brinss <br />ud P,DLss6n Cod€: Thc Conrraclois Lic€nsc Law doe nol apply ro a. oNis ofptop.nv rho builds or impro!6lher{o. <br />and who co ads for such pmj.* vih a Contmdo(s) licasd pu66r b the Conlr:c'or3 Lice6c kw). <br />",,", t)-!a 1e- <br />!-EC!AAAuq! <br />I hEeby amrrn und6 poalry.ipsjury onc orlhc folbsins dRItrario0s: <br />-t <br />hrlc onl will mainlah a Caiiar.ai. oaconml ro Selt-lcurc aor vork.rs conrPdsttion, s povid.d lor bv Setion 1700 o r thc <br />tlbor Codc, lo. lh. pdfomanc. oflh. $ort aor whicfi lh€ ps'nil n isucd. <br />I hav. and will dai ain work€rt comp€Balion isuranc., s r.qutcd l,yserion l?00 orrhe Labor ( od., lor ln pnrnm^n" or <br />rhc sork aor whi.h rhis pqmit is isu.d. My {0*.6 cosFNlion iBurd.. cmi6 od policv nunb.r &c <br />PolicyNun$cr-ExPiB <br />-l <br />ccniryrn.r inrh.pElorman coflh.*ork aor*hicfi rhisp.flnn $ issued.l stallnol onplovan! p.mn ina.r,nMns <br />e 6 ro b<u€ subjEr ro rh. $0.16' compsalion la*s o r calitomia. and asre rhar if I should b€con $6ld to llE <br />works'co,np€.erionpovisioNolScclioa]TOOorrh.LaborCod€.lshall.lonhwnhconrplvNithlhdsclmvisions <br />WARNINC: Irailurc to suc trorlc comper*rion $vc'a8c t unlavful. and shall subjd .n onplovd rd ftininal p ti6 ud <br />.ivil lincs up lo orc hu.dr.d thousd dollm ($l in addnion lo lhe con otconp.Nrion. tt na86 d prorid.d lor rh. <br />s(tio. 1076 of thelrhr('odc. inrer6l dttortuy <br />o[clA8auatr <br />I h6cby amnn und.r p.mlry of ps.jury thd I tun licdts€d uodcr p.oviion o I ChsPl6 9 (co'n'nor.in8 wnh Scclion 7000) 'r Division ll <br />or thc Ausins and PtufdioB Codc, od my lictu. is in lull forcc ud .flsl <br />L,icc6e NunLrr <br />coNlraiJcrlaN.LExDllc-ac[xrl <br />I h6.by amnn undd p.nalry of pdjuy rhar rh&. is . connnrclion Ltdins .8dcv for lhc pdfonnme oflhe wor! aor qhich Ihis p6f,n ; <br />hsucd(S(.1097.Civ C ) <br />Lsn.ler'! Nrme <br />- <br />Lmder',AddN <br />- <br />ATITIIANfDDCIAAAIIOX <br />I hseby ailrn undd p.nalty of pcrjury onc oa rh. lollo*inB dNldal n,nsl <br />Dc,nolilion 1,6'nirsashsros Notifical ion r€d{alResuldions (l itl€,10. P.n6) <br />-R.quird <br />kld olNoidcdion <br />-l <br />cdify lh.l th. acddal r€gulalioB rcgardinB Gb6los rsnoval dc .ol .pplicsbk lo th! p'ojcl <br />-l <br />.oriry rhil I h.vc @d lhis applic.lion tnd sl c lh.l lh. ahov. infomdion is cor..1. I aSre lo conPly wih a[ Cilv &d Countv <br />oRlinancs a d sr,r. ti$srelnt ro blildids .onerudiotr &d fi6€by aurhorize rcprslai!6 o f tbit4ilv sd Counr! ro 6t( upon <br />abovc nmtioncd Dror.ny aor <br />Appli$nl or ,\8tn( SiSnr ,r^r" I I <br />aUz4t<-<_ <br />-/q-/g <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenUlnsulation <br />Roof Sheathing (/U./n :^Ni <br />Shear Wall <br />Framinq <br />lnsulation/Eneroy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif. <br />,'1*) <br />FINAL 2ltltti'M <br />Certificate of Occupancy UI <br />Notes, Remarks, Etc <br />,",",- l(-, ? -/ I <br />I