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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE rD/srG.COMMENTS OWNER AUILDER DELCARATION <br />I hLycb,6i,n u.dd pdDh! ol pdjory lhat I dn cremfl norb rlE Conrraclo6' Licens. liN lor rh€ rollo{in8 r.eb (s(.70 15 <br />Busin6s and ltolGion Cod€): Any City or Counly shich requtB a rEhir lo c66ttud. ah6. imp6!.. ddnolish or Epan M, <br />srtuclue prio! to its isuoncc. also lcqut6 rhe applicmr for such LEnnil ro 6le a srgn.d.rahdi $ar h€ or sh€ is li.ssdl p6u&l <br />ro rhe tovisioN oirhe Conr!.cro.s Lic€nsed Law (Chaprtr 9, Corm.ncing wirh Sdion 7000 ofDivlsion .t ofihc BusinN d <br />Proaessions cod.) or $ar hc or sh. is cremfl lndefron dd fie basis for rh. allcSed crmplion Anyviolalio.ofs{tion 7011.5 bv any <br />applicadforap.nnnsrbjabrh€lpplica"ltoacivilpenahyolnolmorcrhdfiv.hu.dr.ddollds($500) <br />l. as ownd oflh€ prcp.ny. ormy€lnploye6 {nn rvas€s 6lhet sE comrE6alion. vill do th. \'ork md rhcirudE is nol <br />inrddcd or olleEd for el. (Sd.7044. Busin6s &d Pt'.fsions Cod.: Th. Conlrrcloas Licos L.re do6 not apply lo e olv.d ol <br />rh.pDpdy wno t il& or imrror€ th6on. od who do6 such slrl fiinE€ltor hddrorthroqh hB or htr own.mploys. <br />pnvid.d rh.r str.h nnptuvdnnrs tu. nor inrald.d or oilsdl lor elc I[ howda, rh. blildinB or nnprcmor is $ld wilhio o!. yw <br />oa.onpktio( $c o$n6 Buildd will hnv. th. hnd.n ol pmYins thar h. or sh. di-l nor brild or inprc\€ th. pmpely aor lk ErFe or <br />_1. doMd olrhc propdy. m cxclusn.lyconlr..tint wnh li.cNed controcr,s lo consrrucr rhe poJNt (Sd 7044. ts6hs <br />d lttrfeeion Cod.: I hc conti.roa s l,i.cnsc l-aw do6 lot apply ro an ownd ol pNp.dr \rho btrilds or improv6 lhrsn, <br />and Nhd como.ts for $ch lmjcts $irh. Conracro(, lictr.n puBudt rolhc contdcrdfs Lic.c tltrJ <br />I ihexenrpt underssiion .ll & l'C r{n rhls r€a\on <br />]uarKEBs:toltt&lt6rto! <br />DEGAAAIIg! <br />I hdcby arn unds pemlty ofpsiury on€ oflhc followin! deldalioN' <br />I havc od villmoinrain a Ccnificarc ot ConFnl ro Seli-lnsurc for *o sr con]pcns.tion,6 provid.d lo! bvS€lion l70Oorrhe <br />Labor Cod., for rh. pstomance olihc $olt for Nhich lhc pqmil is irsued. <br />-l hav. and willmainrain s.r[.6' cotup.Bar i.n rsuancc.6 r.qun d by sarion ]700 ollhe ljbor Code. tullrc ter.ma c. ol <br />sh,cl' rhE.d is isual M! "orkal .omDmsdioSL^\a F.;"..tr <br />n insuriicc cmid dlolicynumh6 ue: <br />l-rz- 6r II- <br />-l <br />cdifrrhar i. thc pdlormn.. ol$. work aorwhich lhis psmi is i*uen,lshallnol onpkryanypd$n in any mmn.r <br />e 6to b€cone subjdt lo thc sork6 compdsarion l.ws orcaliromi.. dd tuu lhal if I shoold b€.omc subjcl to lhc <br />worl6.onrpmarioopBvisionsofSelion:rT00oalh.tab.rCod.,lshill,ionhwilhcomplywirhlhoErrovisio6 <br />wort6' compqsatioo ov@E€ is unhwtul d shrll suhjer M enplors Io 6nnnd Fmhie'dd <br />$o@d doll6 ($100.000), in addirion lo rlE cosl olconrpeNlion. danares a P6vid.d aor fie <br />Z,\l Lo (c Coi <br />lJ(ltslii.Lrc.Nr]3 !ral! <br />DKL!&IUAX <br />utujd poalryoltiluryrh{ I m li.ajal und- Iro\ ision oacfinplg q (co'.,nd.ins snh salion 7000) ofDilision l <br />J <br />CA.NiIAICIIONI,IBDIICAGEICI <br />I nceby dIun undo p.nahy of p..jury ttar ih6. is a coBrruqion lddins ass., for rhc pdfommc. of lhc $ ork for which lhis p6mi n <br />issucd (Ss 1097, Civ C). <br />atttrc rLDfcLASAIrQ! <br />I ho*y,ftunuidd !..alry.fpdjury on of rhc aollosinS delmtions <br />Iernohr'on PmnlA:bc,h: Nor'ftd'on rcddal R.eul,ions I1tr1.,10. Pd6,Y <br />-L-'Rt!ur€d Ldrcr orNoufi orsn <br />I cdily <br />'har <br />rh. f.d6al rcgularioB res6dinB 6b6ros ro.oval de nor arplicablc lo $L prcj{t <br />Icelifythat lhavcrcadlhisapplicaltuntrdslate <br />ordinancs.nd Sr.te lj\s rchiry lo <br />.b.ve.Mtion.d pmpdt lor <br />,\pplirrnl or Atcnl Sigtrrt <br />^ <br />({) <br />Set Backs <br />Forms/Steeli Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsulation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Eneroy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />/\ <br />FINAL l-3 h.\4glt <br />Certificate of Occu anc <br />Notes, Remarks, Etc. <br />I <br />0$*v ( <br />], <br />4z <br />ir"--.1 <br />ll <br />T-Bar <br />h FlL <br />^ <br />N../- <br />wfltzluEtl ttu L. <br />ol rhc lruin6s ud PDt6sioc Cod., and dy licee is in full lor.. and €ffer <br />rJ A,'ca-\Srtflg4- <br />rF;10 <br />L.nl.r t Add6: _ <br />t---+---f-----T_----