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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUII-DER DEL('ARATION
<br />I h(eby amm undd p.nally of psjury thol I mr €rcmpr frorn thc Contirclos l,icoE Lfl lor lhc follo*in! reffin (s(.701 1 5
<br />asin61 atol Prolsion Codc) Any Cny or Counry shich re{un6 a psmn lo co.srrud. alld. inpNv. dmollh or erBn o,
<br />slracra.. pflor ro ns isud... als r.gune rhe appli.d for such pdfri $ nlc a !+h.d srddnd rhar h. or 3h. is lic.N.d puBUMr
<br />ro rh. provisions ol tlE Conrracloas L'c€ns.d Ij$ (Chaprd 9. Commcncins rith Sccrion 7G)0 of Diris'on I oarhc Bu5in6s and
<br />ProLsion cod.) orrh.r h. or sh. is.x.'npl tha.6oi edlhc bd6 lu rh€ allcr.dcrdrption Anyviolario.ofs..lion 70lls byany
<br />spplicont fors psmil subjc8the atplicel lo acivilp.nallyofnol morclhm fire hun&.d dollffi(t500).
<br />L G o*nd of rhc p.op.ny, or m, cmplo)G silh {.s6 6 their $1. &'npt@tion, wiU & lh. $orl dd rh. $ulr. is d{
<br />i 6dal or oftd.l lor sal. (sa 71].14, ausin* md Pt.aaiioG Code Thc Conradoas Licffi bw do6 nor applt to an oqna ol
<br />rhc tmrEly s|o bdil& or imIrovslh@n. ud rvh. 'loe such *o* himscllor hsFlforlhr.qh his or hq o\n.'nploy.6.
<br />provid.d thal ruch impreroots rc not iootlcd or olT.r.d lor sl. ll ho*68 lne hlildiru or imForoHr is $ld sirhin nn. ra
<br />oacompl.lion. rh. OM6 auiH6 *ill have Ih€ hrdd oaFovin8 rld h€ o! shc did d toild or i,nprcvc thc popqly for thc purFos ol
<br />l. soMd oarh.Ir.pdy, m dclBiv.ly .onrradin! {nh I'cord (mtido6 (, r,ddrud th. tyojd (s.. 7t!4. ltusird
<br />d,t!ftssionCodc:ThcContraclorsLic€nsct,a*do6norapplyromosndolprop.nyshobuildsornnprolcslheren,
<br />and sho conlBcrs for such proje.ls $ilh a ContEclorls) licmsd pusuani lo the Cont.ackrr's l-ic$e liNi.
<br />, a cremrt unds S6hon
<br />1!oa[r:Btllo!!!Ir5^!l(a
<br />DI]CI AfutTIoN
<br />I hacby amrn u.de lohlry oapfjury on ofth. rollos ins dcldal io s:
<br />I hsvc ard will nointoin a Crrificalc of CoN6t to S.li-l6ur. for sork6 co,npsation. 6 pmvid.d ior by Sctnrn 1700 of Ihc
<br />bb.r Cod.. aor rh. paaom c.oith.*6r{ lorrhichdcp@n i tsu.d
<br />Iha!€and wiumai.lain "ork6 conpdation iBuan .. a ..quircd b!sclion1700 oflhcbborCod.. for lhe pFlomrancc ol
<br />yworkdi conrpdeion in dc.!si6 dpoli.y.omb6ac:
<br />-r/
<br />Lt)ircs: 3. i '/y
<br />I c.nifylhar in lhe pffolr@c€ of lhewo* forwhichIhis pernit is tsu.rl.l shall nor.mployanrIE tun in any mm d
<br />e ato b€.om. subj-t ro th. work6 .omFsrion L* oacalilonia, and qlE rh.r ial sbuld b..omc subjd ro the
<br />vortds' composr ion provisioB olselion I700 o f rh. bbor codq I sl€ll. fonhwnh co,nply wirh lhos prcvisions.
<br />WARNINC Fa,lur€ ro sur *ork6' cohrENarion covmae is unlawful. od shall subj.r d drployE lo dn nal !6hlrie md
<br />.ivil nn.s up ro onc hu.drcd rhousa.d dollds ($100,000). in add'ri o rhc cosr of conp.Nrion. d@as6 a Imlid.d aor ih.
<br />sdrion 1076 oarh. LrhJr Cod.. imd6r ed drom.y s rs
<br />,.,",6-3o ''r1
<br />I hs€by affrr undd pcl0lry o I pnjury rhal I an licm*] ondd ion of( h,pls I (commmcin8 wiih Sdtio.7000) olDilision l
<br />oi rhc Busrs and ProletrN Codc. ud mylrcense is in full forcc d eff€cl
<br />t,/eoqlsT9-*t','z
<br />7 I h@by arm ud6 Ftulry o f pdjuiy rh.l thq. is , onsrruclion kodins .sd.y for $c Fhrl@cc of rh. worl lor which rhis pdnil i!
<br />iisu.d (S(.1097. Ci!. C.)
<br />AITI,ICANLDECIAAAIIOI
<br />I ho$y afimullc6 pc.ally ofp.rjury on. olthe follo*in8 del.r.rions:
<br />D.molnion P6nrn$ sb.sbs Nolilicotio. r'.ddal R.uularons (Tnk i0. Pd6)
<br />R.qutal Ldtd oaNorifr .ation
<br />I l cd,fyrhd rhc f.d6rl l+uldoro qedinE ab..rtr rm \rl tuc n., E p'trrbl. r., rhis pEd
<br />Jf,,4arO rrra r r$e raa 1116 apphconon od srare rha[h. abolc infonnario. is concr I asre ro comply s irh all ciry and counry,&din'hc6 d Srare L!trs rcldiry ro b{ilrins conrrudion, dd hr.5, aurho,izc rcprsdlaliv6 oflhis City d Counry to .Tls uI[n lhc
<br />abo\. rndrioned prcp.n) for lp<rlio FurFo!.!.
<br />noou"" ,", n"-'rn".,,* Ml4 o,,. I ' 5 "' t 7
<br />"*^o*", ",r.,u, V -1-lc"< l'lo'i"
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Subf loor/VenUl nsulation
<br />Roof Sheathing
<br />Framing
<br />ln s u lation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It4asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Certificate of Occu pancy
<br />Notes, Remarks, Etc.
<br />I
<br />843
<br />7
<br />UFER Ground
<br />Shear Wall
<br />Flood Zone Certif .
<br />FINAL
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