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BUILDING- INSPECTOH RECOHD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNT'R BUII.DER DEI-CARATION
<br />I hcrehy arfifln undq rEnalry of p.rjury rhd I an crc'np! rnnn rh. Cont.cron Lkcnrc Law for lht lollowins ruN,n (sLt.7orl.s
<br />Busincs! and Prulc\sn,n Cdc) ny Cily or Gunry which rc'ruic( ! rcrnil ro cotrnrucr. xlrcr. inDovc. dcmolrh nr rcnrir uny
<br />srrudurc. prior ro ils ksulncc. !l\o rcquncs rhc applicrnr lbrsuch pcmrir b lilc d silDcd natnr thd hcot \hc i\ licdi{d l)u6urnr
<br />nr lhc provisiotrs orrrr Conklcrois Liccn$d Llw (Chaplcr 9. Connncncirs *irh s..rn ?(xD of Division I ofrhc Bu\inc\\ rid
<br />Prolcssions Corlc)orthir hcorshc iscr.mpr rhcrcrronrnd rhcbrsir r,, rhcalL8cdcxcnr ion. Anyviol ionotsern,nr0:115 by dtry
<br />{rlicinr tuapcrnrir suhjccr\ rhc rppli.mr h rcirilF.xrryornor nxnurh,tr fivc hundEddollanlS5uO)
<br />l
<br />l. a\ owncr oi rhc Droltnr, or Dy cnr,,loyes wirh {!scs !s rhcn wE cootciernrn, will do lh. work jnd lhc slMlw is ior
<br />irlco.lsl or oficrcd lor sslc (Ss.?Or4. Busim$ lnd t'roacsi.ns Cod. Thc a,nr,.kr's Li.cnsc kw docs nol llrply t, dn owin of
<br />rhcpn,Fny wklt ilds or inpn)B drdrn. dd who d€s skh solk hinNc{f or hcrclf or rhmugh hh .r hcr own.mPloyes.
<br />prarilcd rhor \uch inUmkrEnrs e mr inrendcd ontrc{l ti,r $h ll ho{c\rr. rhc h{ildi'rE or nnlmv.mnr is sld *irhin one }tr
<br />olonrhli)l lh.Owncr Buildcr willhavc lhc burden oI povirs rt r hcu shc did frn hoiu or nlll)turc rhc Popdy aor rhc Ptrqnsol
<br />-l.a\o*nc!ofrh.prop.ny.rmcrclu\ivcllcontrri',gwirhli.cnscd.o.lrrclo^l{,LrnrslnrtlhcFn,rlr(S..7(!4.BusmsMd Ph,t6sbn Cod. Ih.Contnttr'sLiccnscL.wdoc{tror.fplyroxnorn.rolIn)nc ywhohulldsnriNfrovcsrh.rcon-
<br />rtrd eho contBca rbr such ptr+cr\ sirh r (i,nrrnn(, licci*d nu^uanr t' rlrc C.ntraclois r,iccn\c I trs)
<br />I arcxcnrfl uDdcr Scdi
<br />Ox ner
<br />lIlatrD&s:clJllfENsaloN
<br />DI.CIANAIION
<br />I h.r.by rlTtnrnndcr |xnrlryofp.rjurtotu orrhc nrlk,{mg d.rlrrurrntr
<br />-l
<br />harc and will Nintdin ! Ccnii.ar. or Contuir t, sclt l n\urc rrtr workc( c..rFnsal io!, rs pmridd nr b, sc.rion 1700 oi dc
<br />tih.r Codc.lorrhc pcrfonnncc olrhc work,ffwhichrhepcnnil ir issucd
<br />_l havcond *ill nrainrrin *orkc6' .o'np.nsarior insurarc,,s rcquncd hySccrionl?00o1'rhc ljborGdc. forlhc!t btnnnccol
<br />thc s.'I nlr which rhn I[yworkcrs ..np..surion i$ururcc clric! ud lxrlicy ntr'nbcr e.
<br />I ccnili rhnl inrh. Filnrnrrccoflhc *.rk lq whichrhi\ Fnnir i\ i\sucd.l sh,ll..r cnrlloyanyrcrsn ir rnym,ircr
<br />$ !\ ro bc.om \uhjNr ro thc wod(dr conrp.nsarion h*! or Calirornr,. n n8rcclhr ill slnult h.totu subjc.r ro lhc
<br />workcr conpcnsnn,n lrcvkio.\ ofSc.rion ll00.frhc Lrhtr Gxlc,I slmll. ionh$irhcomply wirh rls{ pn,vfiotrs.
<br />WARNIN(;: FailLrc k, *.urc workcs conlPcnsarbn corcrua. is unh*liil- md d l \ubrlcr in cmpkDtr lo oiminal pcmlri.\ rtul
<br />civil finc\ !p k, onc hutuled rhoui.fld dollds (Sl(x).o(xjl. in iddilintr lo lhc..sr ol co D.nsarion. drnrScs as P.ovidcd f(tr rh.'::4;ifia :
<br />I beEhy arfirmxnd.r rcMxy or p.rjurt rhai I anr liccns.d undd pmvniotr olchaprcr 9 (conftn.i6g eirh Sccliotr ?(-l()0) ofDivhnrn:l
<br />of thc Ausiresr and Pmtc$ionr Codc. rM m, li.ctrs. is in full lorc and cficct.
<br />*-,.9
<br />SONEItrUEUONI.!!D,INIjTG!N1;]
<br />lhcrcbyrffinnuDdcrpcnilryofpciuryrhlrrhcrcnuconnrucri,nlcndinE4.tr.yrorthcl)crr'onrunccofrhcworkrorwhthrhis[lcmilis
<br />i\\md (S.. lo9l, Cir. C.l.
<br />AEELLCANLDECITIAIIa!
<br />I hrty arnm hder ncnalr, orFcrjury onc oathc rollosirS d..lnr!ri!ns
<br />Dcndilion Pcrn rlA\lEnosNoriltarn,n F.d.ful R.guLrnn\(Tirlc40. Pad6)
<br />R.ouftrl Ir cr of Nor
<br />'licarion
<br />- _l mn'l' rh rh. r.dnal re8ulrtonr rcg.rdm8 !\bc.tosrcmvslm norsfilli, rble !o rhL tmj.d
<br />%3rtt tn, tn* *,a,rri apnlrsrmn.rd s0rc rhir dc rhvc informri.'n h coftcr.I asm ro omply sirh all cirrlnd coun(y
<br />onlinrn..\ JtrJ srrrc ll$\rchriu n' huiuiirr r.n{n'.r hcrchyrurho'i/.r.frc\. rrrnc\ol rlrl\ CiryitrdC.unr,k, circr utr,trhc
<br />rtx,vc nrctrrtnrd pn,pd, for i'
<br />ADpli.nnl or Alcnl Sign!turc
<br />Set Backs
<br />Forms/Steel/Holdowns I
<br />Erection Pads Wr)
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation -t
<br />Roof Sheathinq toll 6 .u-aA/1
<br />Shear Wall
<br />Framing loll tVz U.ccQ 1 ),)
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />[/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL 1\(t
<br />Certif icate ol Occupancy
<br />Notes, Remarks, Etc
<br />{
<br />4./tty ,4.-
<br />Flood Zone Certif .
<br />P{'li.yNx ih.r:-Erpncs:
<br />glvkt
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