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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.OWNI'R BUILDER DOI-CAf,ATlON <br />I hcel,y rflnm undcr pcnrhy oi perjury rhd I m cgnfl fiorn rnc Conhcn,N Liccnsc L!* f{tr rhc n,lhwing rcosn (scc.7o.ll 5 <br />Busincs Md Pnlcssion Code) Any Cny or Counly {hich rcqun s a llemil lo Nnslrucl. alrcr. inlPfl'le. d.mlnbor 6l{n rny <br />srrucrurc- priorro irs issulrcc. also rcquirc\ rhclpplicanr lor suchl]cnnirlo lilca sisncd srurc,r rnd h.orrhc i\ lmnscd turtrlnr <br />b lhc pmvirions or rh. ft, n.rors Li.cns.d L,s (ChJnr.r 9. C.nmrmirg wirh Scclion 7ul) of Divnion 3 olrhc Businc$ rnd <br />Pmfcssio.s Codc) or lh,r lEorshc iscxcnrpt Ihcrcfron. rhc h,sh rbr lhc allc8cd crcmtlion Anyviolalio.o{Sccri,n70-ll5hyxny <br />rrpliclnr fin rpcmir s!hj$.'k rhc appli.anr ro !civilpcnalryofnor rercrhan liv. hundrcd dolla( ($500) <br />-1..\ <br />oqEroflhcproPcn,.(nmycmphlecs*ilhwa8csaslhctelcconrp(n\alion.silldorhcworke rhc{flcrmisno! <br />inrcndcd orollcrcdlorsolclSET()14,BusincssndProfcssi.n\CorlcThcContr.tor'sLicctrktiwdocsnotaprlylo!oowncrol <br />rh. lmpcny who 6!ild\o. i,qmvci rh.mn. anl who dms smh $o* him\.lfor hf*lfor rhn,ulh his or hcr.wn cnplo)rc\- <br />ptuvidcd rh0r such nnprornEnN m mr i cdcrl or oiTcEd for vlc. li howcvcl il'i t itlina or inpmvcftnr k sld wnhin on. )cr <br />ofc.rokri[ !h. O*id Buitl$ will h!\r rh. b{n]cn of pn)vi.g rhd h. .r \hc did tror huikl or imFoE lhc tmtEly lor rhc I'uqre oi <br />I. r\.wmrol rhc lx)p.ny. amcxclDsivclyco ra.tin8 with li.cnscd contmcron h con(rucr rhc fmrccr (Scc ?04r. Bu\imri <br />lnd holtssbtrCodc:lhcC.nrrlcroi\l-icciscl-ardocsno'applyrooo*ncrorpi{,r.dy*h.bxildsorinrpro\rsrhcrcotr. <br />rd eho.o.rB.rrrffsuchphj(tswirhaGm.J.ro((rli..nsudrusu.nrtorhcContracrolsLiccnscLi*) <br />I rmc\cn,fl undrr Scrlo <br />u!ra6[&r-(a!lI!NiiaJl0N <br />DICLAEAIION <br />I h.r.6yrr'lir undcr|xnalrtolIrrjrrroicofrhcf{,lk,sin8dccl&ari(trN: <br />Ihilc.riwillrminriinrccnificolcolConscnrroSclllnsur!torworkcncotnDcrerion.aspnlidcdforb!SccrionlT{Dofrhc <br />bbor Codc, for rhc Frlnrror. of rh. woi{ lor whi.h rhc p.nnir n isucd. <br />lhrvcrMwillN.iin0haorkcricomDcnsathninsu.rncc..srcquircdhyScdi,)nl?(xr.frhclrhorC{dc.Lrrhcn.rronruncof <br />y sorkcG .ompcnqrion insurlrcc c.tricr !ftIpolicy nlmb.r 4. <br />t <br />r)to-tL-ty <br />Ircnilrrh,r i',rhcp.rfonfutrccorrh.soArorwhi.hrhtpcrnl n i{{kl,I {hill ur cnrlloy rtry ,cr\on ir ony rnncr <br />\) r\ h b....r subjcd h r he solkc,\, conrEn\{lion hw\ or C.liromir. und lsrcc lhrr ir I sh,trkl tr..ft subj.d tu th. <br />$orkcri (mp.nsili6 ptuvisions ol Sccl iof :l?(xr oi rhc Lrhrr Cqlc. I irll. iffrhwirh ..i!rt wirh rrrr. fmvnioN <br />IVARNIN(; f ilure r' {.urc *orkcrl co rEn\ari(rr otrliwtul- ind shall srhjd in cmplorr h siminrlprmlri\ rnd <br />ion.6nug.s r\ pnrvidcd f{r rh..i!il finc\ trt, t, dnc hundrud rhousud dolles (SI00,flX)) <br />srrn . rorts in,\. l lthr ('ndr.'nr^rq 0fld dL n y . le.. <br />x*6a\'\1 <br />D[CI.A8Au0N <br />Ihcrbyaffinnund.rpcn.llyofFrruryth.rIarlicctr$duMrpmvisionofCh.prs9(.onnmncin8*irhScciion?mO)ofDivisn l <br />of rhc Bt\ines Md Pmfc*ions Cod.. dd 'nyli.cnr i\ i'r full forcc d|l cffc.r <br />\ /*" <br />\.,. <br />b11L1 <br />{4v lt con,r,(,or <br />CONSIBIJCIIQN.LENDING.AGI'N.gI <br />I hcrcby afln'.undcr pcnally ol l{.jur! rhar rhc,c is a consrruclion hndins oscky r.r rhc p.doflmn.c ofth. sork lnr which lhh pcrmir n <br />issucd (Scc.3$17. Civ C.). <br />AIPLICINLDECIAMIION <br />lhcnh) afrmr u.dn p.n.hy ofFrjury orc ollhc lollowin8 dcclorations: <br />Dc'mlirkrn Pcrmns-Asb.ios Noriicntion F.dcr.l Rcgulnlians (Tillc 40. Pon6) <br />Rcquir.d lJtr.r.rNoriff, rrbn <br />nll'ly wirh rllciryrnd counry <br />Ciry ndCouiryro.nld uB),rrhc <br />_l c.nify !hrr Ihc tad.rnl r.lxlnri,,trs rgird,nC arh.fo\ rcnrv.l arc tror rtrlic.6lc lo rhis pmjccr <br />.11-\( <br />Forms/Steel/Holdowns <br />Erection Pads <br />SLAB Floor <br />Subf loor/Vent/l nsulation <br />Rool Sheathinq <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lVlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />A <br />'1"5*/g k"w)0, <br />Certificate of Occupancy v \_/ <br />Notes, Remarks, Etc <br />I <br />COMMENTS <br />Set Backs <br />UFER Ground <br />Flood Zone Cerlif . <br />FINAL <br />4tru1