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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS (,WNER BUI I,DER DttI,(' N 'IION
<br />I nercby amnn uidd pe8lry oi pdjury rhar I m cxemfl fiorn rlE (i'nrr6cr.6 l-i...s. ln\r lor rhe aolkN ifl! rer$n (Se 701 1 J
<br />Blsin$ and Proasion Code) Any Ciry or Counry s,hich requtd a norrir ro consltu.r, .lre, irnflovc daFlish or repai ony
<br />sltucxtr., Eiorro irs L\suM.e, rho rcquir6 rh. appli.d lor 3u.h tmni ro lil.0 si!.ed stat.nr.nr lhai hcor shc G liccNcd pusuanl
<br />o rhc trovisba otthc Cnnracff s Lic.nscd l,rv (Chapr.r 9, Conlnencins qirh sccrid. 7000 oiDilknn: I oarlr uNnrs and
<br />Pr ofsion! Codc) or lhar h.orsh. is ercmpl thdcfton and rh. h6L lor rhc .llcued elsnption. Any violation oaSdsn 7o.l1.t h! any
<br />applicdl ao, a p€flnil subjdsthe applicanl lo acivilp€nahyotnol morerfiM nve huid(d dolls ($500)
<br />1.6 oLvn6 ofrhc pop.rly. or myenlPloye *nn *a86 s th.n $k corrp.Bariotr. trilldo rlE $orl Md lhe slruclut is nor
<br />inhded or o fid.d ror sl. (5(.70,1.1, Busi.6s ed ltolsioos Cod.r 1 h! Conradois Lic6F tjrv &i6 nor aml, to an oNns or
<br />lhe pmpdy vho toilds or inproiG Ihq6n, d who doB such \ort him.lf o! hdell or 'hush his or h6 olvn .mrk'r€6.
<br />povid.drhal such ilnprelsnqls e€ nol intdd.d or or6Ed fo!el..l[ hos6 q. thc t{iklinr o.impm\cN t$ld\irhin,,n.rG
<br />otcompl€lion.lhe(nvn r Build6 will havc lnc hrd6 ofUovinB rhd hc oi sh. did mr hrilJ or imraorc lhc pnpoly for thc pu,rre of
<br />L a os id ofrh. ptuleny, m .xclurnrly ..nt acrins Nnh li.ctrs.{r co.tactuF ro consrto.t lhc O (ier ( S€c ?0,14. &B{rss
<br />andhrtusionCod.:lhcConlracloisl-iccnscl,fltrdo6trotoDplyloanorvn.roflnop€nv$hohu]ldsori'npnv.srh6(n.
<br />and who.onimclstoru.hprojeGwirha(onrmcro(Olic.6.dptrBumtro'lEconrmdorsl-icosel,a\v).
<br />I M.x.hpl unddsdion . B. & PC forlhisrGon
<br />1!O!(!AllO!!!E!,14l.!OIolct &tllot
<br />I h.reby amin undEr pdahydlpdjuryone6arh. aoll.\rinS delr ions:
<br />I hav. md will mai.tain. carin.ar.ofcoBcm h s.lal6ui. ir \rorkm' camD.nsar ion, os rmviden for b! S(ln{ lTLt orihc
<br />tjt rcdd..aorrhcDdlomdc.ofrh. ork lor which rhc ponir ir isucd
<br />-l
<br />hav€ and will nun air Norlm conpens.lion i6uran.e. a r.toned bySdion lT()Oollhc LahorCodc.lorlhcrFfihnanccor
<br />lhc sort for rvhich lhis p.nil is isLEd. My $0116 comFnsalion insuranc. caris ud policy nu'nbs d€l
<br />ALi@.rA r"l,r:r*}r..{ a
<br />4b-6<11C-d-d2-el,\k
<br />l.olilylhar in rhe prnrmaice olrh. $ork nn \hich thh r t s!st. I shall ior .id.) inv lrn,. n rnj flankr
<br />$ 6 lo b€.om. sbjer lo
<br />'he
<br />worlds' comp.nerioo l.ws of cal i0.ond iSrrhar ill should b€(on'c bja' roll'.
<br />*,o*sl comt€Mtion lrovisiotrs of Sdion l7O0 ollhe Labor (
<br />W,{RNINC: Failure lo suc !vorkr6'cohlEnsdion corcmge
<br />civil liocs up lo one hundrcd lhousand dollG (1100,000). i.
<br />ilh co nfl! \rlh lh.sc p(risii,ns
<br />rhall sih|{r nn dnpli,y.. t, G.riml |f,n.kia ,.d
<br />olc.n,t).i\rrf . d.nnrs.s rs 11o\ J.(l tu rlr
<br />Code inl€r61 and axorrcy s
<br />(b r(r,
<br />I llcBby a,nfln rnder poalryoitErju'y lhar I an li.€trKt undr ,n.ncins $nl sdion 7ur0)oaDnision i
<br />of rh. Busirs and Prolsio6 (odc. ed nrr lic.ns is i.ltrlllorce
<br />q,4 IU 5o)$(
<br />ca srBucuoNL[NDlNc_agElcf
<br />I ncEby amnn undd p.nalryolpcrlurylh,l
<br />'h6.
<br />i! a sGrru.rio.lcndos asoc, aor di.tda.nrnre ollh. uo lor\ i.hlhbFini' is
<br />issu.d lSe 309?. Civ. C.).
<br />affuc lfD[cLlaaroN
<br />lMyammnndq pdrolly of pd.,ury one olthc lollowinA dml.rorions
<br />D.molirion Pmns Asb.sros Nolili.arion F.d6al R.gularions (T lr40, Pa16)
<br />Rcquncd Lcll{ olNorifi !drio.
<br />I cdifrrlu rh. feddal rcsulari.ns rmdviltrc tror q'pli.abl. tr rhis pojd
<br />I ceailylh.I lna!. rcad lhis applicarion !e lnlonnarion is cordr. I 0srero comply\nh aU ( iryand Counry
<br />ordi.anc6 drd Stalc l-aws r€ldirg ro buildin8 .ulhorizcr.?6d alne ollhis Cil) nnd (ounly lo cnr( upon lh.
<br />obor nmrion.d p'otf,'1r lor
<br />s]'4to,\pplimnl or,\g0l siqnrrtr
<br />Fo rm s/Stee l/Hold own s
<br />"t
<br />Do76 -=H,,.ttt d),
<br />Erection Pads I U \!-/
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />In sulation/Energ y
<br />Drpvall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />En gineer Final Report
<br />Flood Zone Certif .
<br />r\
<br />FINAL - r-r1 V"\{-)Cll
<br />Certificate of Occu pancy
<br />Notes Remarks Etc
<br />Set Backs
<br />Pool Fence
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