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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE COMMENTS OWNF:R BUII-DER t'ELCARATION
<br />I hcrcby ronnr und$ ncnnky or lxjury rhal I a'n.x.mpt ronr rh. G)nn&ros l-i...s. tjw ror rhc nJllowin8 r.N (sc.-,1:11.5
<br />arsinc* and P.or'csion C(xle): An) Ciry or Counr) which rcqntcs ! a.rnil lo corsrrucl. rllcr. improve. demlish nr rcnJn any
<br />stru.lurc. nrin b ns k\udn... rko rcqutc\ ihc rypli.anr f.r {ch pclmit ro lilc d \ilncd dar.ftnl thd lt .r shc ( licctrrd pursuMt
<br />r. rhc ri'vi\ions olthc Conrracrois Licensed Law (Chaprcr 9. CoMrcncin8 *ith Sccrion 70Oo ol Divhion 3 or rhc Bu\incss and
<br />Pmicssbns Cuil)orrhar lf,orshc i\.rcmpr rh.Efrom,nd rhcbrsh (tr rhc rllc8cd .x.opri,n Anyviohrnnrofs{tkn70:ll5htrny
<br />applicur for rFnnir subrcrslhc q'tlicant ro acivilpcnalryoinor mrcrh.n fivc hutrdrcd dolllm {$500).
<br />-1,0s
<br />ow cr ollhc po,rrry. or my.nDlorccr sirh wag* n\ rhcn v,k .lnll)cnsarion. willdo rhc wolk rnd tl* strucluN i\ trur
<br />inrc cd orontrcd ior qb (S( 70l,l. Busim\s rnd Polcssiotrs Codr: Thc Ornlrrror's Liccnsc t w d@s n r alply t' m o$ncr ol
<br />thc F)pcdy who builds or ihltrorcs lhcNn. .ntl who dds skh sort hinNclf or h.r$ll or rh$u8h hh or h.r own .mploycc{.
<br />pr.vidcd rh,r sxch inpn,vcdnh m rt, imcndBl or ollcrcd aor qlc lt ho\rEr. rhc hilding or impmwnrni is sld wirhi]r otu Fa
<br />ofcom0lclior.lfu O*ncr Buiklcr Billhavc thc hrd.nolpo\tr8 rr rr or shc drl mr hitl or in{,rcrc rhc IBIMy rhl thc luqFs ol
<br />l- asowncroflhc prorcny. rDcxclusivclycofftr lirewirh licc scd co roclorlo.onsrrucl lhc pro.,ccl lScc 7044. Bu\irc$
<br />,.d Pt lL*sir Codc: Thc C.nkn trt Liccnsd L,wdd\ .r apply b a. owncr .f pn,l.dy sh. buildsor nnprovcs licrcotr.
<br />ud sho onrmcls aor such pmJcds wirh r Conrocions) liccns{ pusuanr to rhc C} rucroisljen$l!*)
<br />-l
<br />amcicmrr lndcr Scction-, B &PC lorlhirrcrson
<br />D.te: Oener
<br />$OR(ERY CO,1,l PEI\SAf l(lli
<br />DECLAIAIION
<br />I hcrcby llfinnunder rcnalyorpcrjuryonc ol'thc folbwnr! d.clm'ions:
<br />lhav.lnd$ill'uinllin!Ccrlifi.ateotConscnlloSclfltr\urcritrwotkc^conrllc.slrion.asnrovidcdlorhySccrion.lTOnofrhe
<br />tibo, Gxlc.lor thc lcrfonurcc otrhc so rbrwhichthcDcanir is nsucd
<br />rhc trork lnr {hrh rln\ |{rin i{nsucd Nly$ork.^ .o'nt{n\rriir in\urrm..xri$ xtr(lFni.} nlnh.r ar.
<br />_a
<br />-l
<br />ccnify rlnt in rhc pcrlbrume oithc $ork f(r wl .h rltir r.rnir is issu.d.l lhnll nor ctrll,loy itry p.Mn nr any nMncr
<br />v, a\ t, hcc.m rutjccl to llE sorkcn'.onr€n{ im l{usofcaliturni.. rnd !3Eclnrlil I should bccoaE $h]cd to rl'(
<br />$ortcr conrp.nslrion l)n,vi\ions of Sdion l?0Oofrhc t-lbor aodc.Ishrll, rbnh*irn coq)ly wirh rhos tmvhions
<br />WARNINC: tailurc lo scurc workcE otrrp.nsdn .ov.fuE. is unl,wrul. and d l subi..r ! cnlploycr to rntunrl Frrh.( rd
<br />.ivil tincr u|] ro onc hutrircd llDus.trd doll{s 1$l l additi.n ro rhc cos of.onpcnsari.n. drtrrScs as tovi:lcd tu rhc
<br />sccrion.10?6 ol llN L.tor Oxlc- i,lercsr nnd rrrorNyk
<br />DECIJf,A.I]QN
<br />I hcrcby,ffirmundcr pcMlry of Frjury rh,r l,m lienscd uoder provnnrn of ChaFrcr 9 (omncnci.g wirh Sc.lion rO00) of Divkion:l
<br />or rhc Bu\incss and Protessions Codc. and my li.cnsc t in flll foR and efiect.
<br />9?so v y
<br />u^", E-13-/8 .-,6o -.<1t &-Eu-a
<br />I hcmby .fftrm undo ,rnally or Frjury rh,i rhde ir d oinrud ion kndins asc yforth.psrotr1@.of rhe *oik ro.shi.hrhk Fmir ir
<br />irs&d (scc.1097, civ c.).
<br />AITLIIANLDI(IA&\II!)N
<br />I )rrbt dlnn ridcr t^.- rlry of n rjlry om of rhc folloqing dc.hrJrnn,s
<br />Dcnxrlirirnrl,crnritr A\5cdosNoriiirrrid l.dc(l RcSuhlirff (Iirl.40. 1fi6)
<br />Rcqrn.J larrcr ol N.ri,icrriu,
<br />I c.nilyrhi rhc lcdcrrlr.SuLrions mE dinS rsh.{o\ rcnN!al ir. Nr ltplirahlc h rhir I,('l.cr.
<br />-l.enifyrh
<br />lhlvcr.lldIhnrpthcaliotr d(.tcrh.rrhc.t vc r.nMrion is .omt. I rerc to .onDly wnh .ll Cny and Counry
<br />.rlrrn(c\ rnd Sl c tr\rsrchlirr B(oNru.r i. d hcr.hyNrh.r2c rcprcsctrurivc\ of rhtCiryrndCotrrryIocnr$ qn th.
<br />$.vc n{rrnnrd nR,pcny f{r
<br />.2 6,.)o-.,",. ,/\pplicx l or A*enl Signar(R
<br />8".!-I1A
<br />?-/ I
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVlnsulation l
<br />Roof Sheathing 9/rsltt &u,nL-1a
<br />Shear Wall
<br />Framing
<br />lnsulation/Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL A ('v ll7 UlrtDlb /E>-
<br />Certificate ol Occu Pancy I ('-
<br />ID/SIG.
<br />Notes, Remarks, Etc.
<br />6'-.-2rno"".8--t?-r8,
<br />bndc't Add:cs.
<br />-
<br />C/ c (;
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