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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.O'\tNI'R BUILDIIR DELCARATION <br />I hscby afiim u"d6 pdaly ol pcrjury &ar I @ d.npr fr.n Oc Contractors Ltcn,e LaN lor lhc fdlowins l6n (sd.70l l.s <br />B6in6s and Proa6io. Codc)r An, Cily or County whi.h requn6 a lrmn t. conntu.r. alrd, inprov., &inolish or reFn y <br />sncntre rior ro irs issumcc. oGo rcqutB th. applicanl lor such p6.il lo filc a siSned {ddnd th0t hc or sh. G licdeJ puduanr <br />kr rh. flnvnioi. olrh Cont..clo.s Li€cn*d La$ (Chapr{ 9. Comm.ncin-! \rilh Sdtion ?000 of oivision I ollfic trusin€s md <br />Prulcsioas Codc) orihat h. or sh€ Ls €rcmpr thF€from ond the basis for lh. all+.d .rdnption. Any violationolset{n 701I 5 by any <br />applica rorapnftnsubjdsrhc,ppli.etroa.i!ilpenalryolnor,norclh fivc hundr.d doll&s {$500) <br />l. 6 owncr of the r,!Fny. or hy cdplo)G * nh *a!6 s rhcir $lc conposation. * rll do rhe uo* and lh. sMG is nol <br />inroded or orced for el. {Sc.7044, ausin* ed ftofNio6 Cod.r Tfi€ aonra.rors Lic.N bw do6 .ol spply lo u oMcr oa <br />lhc pmp.ny \rho buildi or improv6 lh6o( ed vho do6 such $rt hidsctf or hds.ll'or Ihroush his o! ho ow. .toplor-.6, <br />provided rhal such mpre\ oEnll ft nor i dd.d 6r olTad ror sa]. If. hoN66. de ttuildins or improroMl is e6 Ni(hh on. !w <br />olcompldion. thc ()\116 Buildo siU h!!. rhe hrdo ofFovinr rhd hc or sh. did nor ttuild ar irnl,olc lh. pmpqly for lh! purros of <br />-1. <br />s ownd oflh€ popdlr. dn cxclusiv.l, coolrading vilh li.osed co.lraclo6 lo onsltu l lhe Fojct (Se ?04.1. BB'oe <br />md Pmfsion Code Th. contactor's Liccnsc La$ do6 nol apDly to d otr.o o f propdy vho builds or inrprov6 thes.. <br />&d $ho conr6.l! for suchFojds wnh aconlr.clo(t licm.{ pnuunl lo lhcconttdor's Lic@c k$). <br />-l <br />d .r.npr undd 5..1io.- B. & P.C. for lhis t!e. <br />D.(c: Onn..: <br />tu9B[EES:lOI1rEllAl!9XDlict tsduoi! <br />I hedbt.llinnundsp6ih!otrglurloncoflheloll vinsd{lalalioos: <br />-l <br />hrv. md *ill minbi. a adificar. ol Co6dl lo Seli-l6urc lor Noikes onrpcnstion, s prrrided lor by Selion 1700 olrhc <br />l-ahtr Code. fu rhe Fao.nd.c of thc solt for which rh. p6nn is irsu€d <br />lha\e andsill nrrinlain Nork.rs' comrcnsaxon,Euran.c. as (tuir.d b,s.4ion 1700oflhcLaborCod.. forrh. PGt moceoa <br />Tnaardeokyrudb6e <br />the Nork forrhichthispornir 6 ilsuql. Mywork.n conrpos ionfi,erc'r A)af,av,ql /,4'r -7 <br />_l c.niryrh.r in rhe pdaonne.. olrhc sork ior ![ich rhis pdmn is issued, I shall nor dnploy rny p.Mn in any nan.r <br />$ 6lo b..onE subjd to lhework6 .onp.6a1io. las. .l Calitumi,. md aEG $al ifI should b.com. subjrt bthc <br />rvo*s comlEnslion previsios ofScdion -1700oalh. tih,r ( odc.lsldl,fonh\vilh comrly *irh lhos.tovbions <br />WARNINC: Failurc lo suc wort6' conposation corras. is u.la*ful, d sh.ll subjd e dnployE to ciminal FtrhG dd <br />cnil ,l.d u! ro on. htrndred thotrsnd doilc (!100.0S0),addilion ro Ihc cos oacompcne <br />Lr('L:rsriD ( ()N't R,\( I0R <br />J]ICIJ3AIj!]I <br />I hd.by amn. und6 F"ahy ol pqjury lhat I d licots d und6 r,ovision oachapts 9 (commdcins sirh sclion 7000) ofDivision 3 <br />ol fi. Burins dd PoaBsios aodc. od ny licnc is ifl full forc€ dd etT{l.3t_,/. <br />:FC <br />aftucaNlD[ct aE uo! <br />I hd&y altm und6 p€nalry of pnjury o.c oa rh. lolloNing d4ldariotrs <br />Dcnrhion P6nits-Asberos Norifi.dion Fcdnal R€lulalions (Tnk 40. Pe16) <br />-Requied <br />L€tld olNotifi @rion <br />-l <br />cqriry rh.r rhe redd,l <br />'rgulario,s <br />eBardins sbeios renoral . nol.pplicabl.lo rhG ptol.a:1 <br />I.dif,rhd I h c re.d lhir applicat <br />ordina.cs -ld srdc Ijvs Elarinx ro bui <br />ion dd slate thal the aborc inaonErion is cond.I ssre to complywnh allcnyand Counly <br />ldins corotruclion. d hscby aurhornt relrL*nlar iv6 ofthis Cily od Counryro <br />abolc nentioncd prop.ny for <br />\t,t,lictrtrr or \[rtrr siInirtrrr tt <br />') u\ <br />b <br />Set Backs <br />Forms/Steel/Holdowns <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVlnsulation <br />Roof Sheathing <br />Shear Wall <br />Framing L I 5\6< <br />ln s u lation/Energ y <br />Drywall \>tb <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />t (.f tq ,,,1 '//s(1) <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />FINAL Ai,e, <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />COMMENTS <br />Ereclion Pads <br />t, <br />1 <br />T-Bar <br />Flood Zone Certif . <br />VsesoX <br />o"" /t <br />collBlJcuaNI[NDldcAclncI <br />I hercby aflim undcr p.nrlry o f p€rju.y thd rlB. G a comtrudion lcndins asdcy for rh. pclblmrc€ ot lhc vork ro. $hich rhis Fmit is <br />issu.d (56 1097. Civ C). <br />L.nle,'r Addrs: <br />-