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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE tD/srG OWNER AUILDER DEI,CAFATION <br />I hd.by rfii"n unda raahy of r€rinry thai I an .x.nDl from lhc Co.tmclon l-tense LaN rorlhe follo*in8 teMn(S*70315 <br />Busin6s d rrotKsbo Code): Any Citt or Cou.ry \hich rqpnd . Fdnil lo c.nslrucr' alr6 inprove. dmolih or rcrun v <br />$rucru€. prioi r.r ils irsurncc. also r.qut6 th€ .ppli.d lor si.h p.mi to fil€ a sisncn shtdtrd lhal h. or sh. is licflicd pmu r <br />to rhc pmvisioG oflhc Contrclors Liccnsed l-3rv (Ch.!lcr 9, Cominmcins wilh S(tion ?000 ol Division I dfih' Buli'Rl d <br />Prol€sionsCodc)orlhalh.orsh.is.xempllh6elionedrhtbsisfo!rhealles.i.rdnprio..Anvliolart'nolsdion70115bv,n) <br />oppt(a for ap.mn subj.clsth€ applicanrloaci!ilpenalryolnol'notrhMliv.hundreddollds($500) <br />-1. <br />ai oM.r oarh. Fo|Eny. o, my cmplo,6 \rnh s,*6 s lh€ir slc conPs,rion. will do lhc Nork dd th€ stnrclu€ t nor <br />immddl or offs€d fo; s;b ( 5<.7044. BNins nnd ftol6siom cod. Thc (rnta.lof s Lic.nf I rs do6 nor appl, to o oMs oi <br />thc pfl)triy reto bdildr or nnprov6 rhsstr rl who do6 such so& hims.lfor hq*lfor nro!-!t hG or hd ow..mplovc6, <br />pro,i,l.d lh.r ru.h iiFolmns s€ mr idoddt or ordld fot sl.. lL lt*66. dc ,rildins or imp.ordmr b $ld vithin onc ,s <br />ol conpldion. rhc (nwq Iruikjd will hav. rh. hndo offl o\ins tha hc or shc did nol build or inprcvc rhc pEpqtv for lh. pu4rs ol <br />-1, <br />doNn&oarlEproFny. m.xclusivcly.onradint wirh lic€ns.d contadoB ro conslru.r thc pojd (s(. ?0'14, B6ms <br />dd P:!ftssion Codc: Thc cdnlr.crois Lic€nsc l,aw do$ nor apllyto ano*ns orpro!.dt Nl$ builG o! idprovB thdon. <br />and who.onta.Bfo.suchprljca$ilhaContacto(9lic€trEdpu6udltdrh.ConlracroisLicd*tiw) <br />. B & P( lcr rhn,6on <br />WORKERS' COIITPENSATION <br />SEC!,ABAIIAX <br />t n6eby amro undd Fnall, of pslury otc oflh. lollowins deLralioB: <br />-l <br />hav. rnd will 'mi .in 6 Cedificarc of CoG6l b S.lal6urc for workm onrp.n$lion, 6 pslid€n for bv Serio. l?00 ofrie <br />Labor Cod.. for th. pdaom ceof Ih. wort for which the pmil is ('u€d. <br />-l <br />hav. and will mainlain wo d conpcB.lion iBU! c..s rcqut d bYSation1700 ollhe kbor Codc. for lh. pqaofln.ncc of <br />rhc wori for {nich $is p.nnit is sslcd My sskdt comp€Mlion insr&.c ffid md policy numb6 6c: <br />I c.nrry rhal i. rhe pclorMncc ofthe sork rot $hi.h rhis p.mit is Gsucd. I sh3ll nor onplov inv pd$n in.nvnd6 <br />$ sro lx.omc subjsl lo lhc soik6 conrF.salion la*sorcal,aomii. md osEe lhal ilI shorld b.{o!n€ subj(' to lh. <br />sortm conDffilioo provEioroofSslion l?Ol) olrhe I.bor Codq I shall. fonhsnl.onvlt {ilh thoFprerilioN <br />\IARNINC: Failur. ro hure Norkrs' comFnsarion .o\mtsc is unlasful &d shall an fipbrq lo dimmal Fodri6 <br />r. onc hundrcd thousdd ddllm ($100.000). in ad,litioo ion. daraB6 6 provid.d lor th. <br />Scclion 3076 olthc Labr ntqesr dd tlrot,Ey s lc <br />-l I <br />I hc,eby amm undn poahy of psjury lhar I dn licds.d u.da prorision olchapt6 9 (comnmcidS $nh S..lion ?00{D or Divisi'r I <br />oa rh. Busins ed Pofsio6Codc, {d my licdsc is in lull for.c dd .iIdr <br />It <br />ud q?17{v <br />I 0 <br />CONSTRUCTION I FNDIN(: AGENCY <br />I hs€by aflinn und€r pcnally olpdjury lhal lh6c is a coturru.lio. L.din8 ssdcy for rh. ldaommc€ orlhc sorl aor ehich this Dstil is <br />6su.d (S< 109?.Ci!. C ) <br />APPI I'ANT NTCIARATION <br />I ffiy rltm undcr poahy of p.rjury on oflh.lollovins dclrarionsl <br />D.Dolirio. Pmns-Asbdlos Nolilicotion F.d6al Rcsulalions (TnL 40. Pan6) <br />-Rcquncd <br />lllld of Noti6orion <br />-l <br />cdiryrhalrn fcddol rcsulalioN rcsrdine sb.stos rmoval 6c not ,tplicabl. to ihir poie.r' <br />I cd1iry fial I havc @d lhB al,plicsliotr !d st.l. lhal $. .boB infonnotion is cod.d I alre lo complv wilh all Cilv and Counrv <br />ordinanc6 and Srarc lzws r.l,rin8 to buildins cotuloclio oilh6 C It atl Cotrnrylo cnrq ulmnthc <br />,h,!. rnsrioned laopeny litr *,. \'./2a /t D\pflirn l or \Artrt SiA rlut <br />Pernrir@ nrnc (p.inl): <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenVl nsulation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <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 />)/7////g -?&t ,'l-/Certificate of Occupancy <br />Notes, Remarks, Etc <br />COMMENTS <br />FINAL <br />),./-,\--/-Z^- <br />I