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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BTIILDi]R DELCARATIoN
<br />I hcrcby allim undcr pcnolry of pcrjury rh l MIcxcnDl fior rhc Conrrnct,B Li.cnt tiw lor rhc nnt,win!,crsn (scc.7oll5
<br />Busincss rnd Pofc\sin Cod.): Atry Ciry or Conmy *hic[ r.qun . r lEnnir b lnoslrucr. ahcl inPn'vc. dcmlish or reP]ir dtry
<br />stucrr( prirb ir\ issuancc. rho rcquircs lhcrpplicr f,tr su.hrrnnir lo ljlca \igned naicnt rhd ltor shc n liccisd Pur\urtri
<br />to lh. FivnnnN ol llr Conro.nn s Li.cnsd Llq (Chlptcr 9. Comnrrkins sirh Sccrim 7UD of Divnio l ol rhc Busirrcs lnd
<br />PFfc\li ns Codc) .r rhar lrorshc ircxcmpr ltcrcliorand rhc ha\i\ fd the lllcScd cxcnyion AnyviolarionolSccli.nT0.ll5by ny
<br />,pph.rdnrrlcnnirsrbjcclsthc!mlicrnrk,r.irilr.nrlryolkrarrcrhrnfirrhundnddolh6($5(f))
<br />-1.
<br />!s o*ncrofrhcPnt ny. ornrrcnfloyccs rilhwoac\ r\ rhcir $lc om|xnsd ion. sill.L, rh. w.rk dl rtE nBluE i\ nor
<br />inc Ln orofcrcd for slc lsa 7044, ar\iNrs and Pdassi,,ns Codc: l hc Contacttr i Li.cnsc ljw doc\ norurply ro rtr lwncrol
<br />rhe pft,rcn, who hrilds or ilprovcs thcNn- ! $hodm\such*, hnnsctf.rhcrclforrhn'oghhno!hcrowncmployccr.
<br />povidcd Ihor \u.h inDmrmnhdfr, irncMcd d of,arcd for siL li howcvcr.rlt huildirB o. inD.ov.md is$ld('hhi'r,,nc rrtr
<br />of.on{hrion. th. Owmr liuillcr will hnvc rlf burdcn of |,ovin8 rlN hcorshcdid n huikl or in{n)t thc Pmrdy fitrrtrnuqncof
<br />-1.
<br />as owncr ol rhc l,R,pdry. jncxclusivclycotrrEcrins *irh licc \cd .otua.trtrs ri sn,e ru( rhc Pml..l (Scc. ?O'14. Bui.os
<br />md Ptults(irn Codc lhcConrrucrnis Licenrc Las doc\ n.r rpflrlo in owrcr of Pn,If,dy qh. buil&o! inrPtov.\ rltcrcotr.
<br />lnd sho conrrrcrr tr su.h pnrjc.G wnh ! Co m.ro(\i li.cr\crl rd^u,trr t,rhc(bnlrackr'! l-icc.\c tis)
<br />I rncrcnr0l unl.r SNoo
<br />]IOBf,};IIIAMIINIAI]O!
<br />IIE!:I.ASAIION
<br />I hcrcby 0flirm utulcr pcMlryortf,rlury.m ol rhc Iollowins dshrtrrion!
<br />-lhrvcand*illDinrain,C.niicorcofCotrrcnlroSclllnsulcldworkcNconllcnslllion-^providodlorhvSccrion.lT(norrlthtDr Clic. ror rfic pc ormn c of rhc work fd whf,h rhc lcrmil h issucd
<br />-l
<br />halc xid sill ii ai. workcis conrpcn\alion in\!ran.c, as mrluircd by Sccr i{nr ]Tm of thc tibor Codc. fix rh. pnhrmrcc ol
<br />rhc sorklnrwhi.hthis pci,nil is ilsucd. Mytorkc( c.n{cns.ridr irsunncc clricr dd B,li.ynlmbcr !tc:
<br />t ccnilyrhlr in lhc penormn.cofrhc work lor shich rhis ptrmir ir hsucd.l shrllnor cmPl,)r!ny Pcsor inatrvardncr
<br />$ tr\ ro b.$m subicct to thc worts conDcnsdnni llws ofCrlilnnia. lnd lgrcc rhar ifl lhould b$onE srhrccr ro rhc
<br />*oaci( ..nrpcnsatnnDmvhions o, Sc.rnrn .l7m of I hc Lltn Codc. I shall- fonh*irh .onrDly wirh lho$ ttuvnio$
<br />1lARNINC: !i'ilur. b $.urc workcrs onrncnsoriqr i. unldstul. rtrd \hrll sul,jccr n cnl o)€r ro oirrral Fnnhics d.d
<br />ro onc huid'.d rhousrnd dolhn {$ll rcn lo rhc..n ol .on{i.n\rL.rr. d.ma8cs as !nrvi.tcd l(tr rhc
<br />S..ri llrr6olrh.lrh, (,xlc. i' crc! rd
<br />o",., 8:6 Ld
<br />L[r,NSX!_(l])t&tlIAXlllllllltarllJ!
<br />I h.rcby nfltn utrdcr I.noh, ofFrrxry rhnr I u li.cNnundcr l,f\Fi ni,fahrnrcr!rcumrmN'ng P[hS(ri{ 7oi('roll)ivkio']
<br />nr rhc Bxrn.s rnJ Pofc\{.rsCoJc.nnd n.) hcn-''. rulr li,r,c o.'d cric, r
<br />tAtvwt 1ro-* n.,*,,
<br />."",u4
<br />CONSTRII(:TI(IN I FITDINC ACFN(]V
<br />I trrcby urfinn uMcr Fnrllyofpcrjury rhar rlErc is i.onsrfldiotr lcndirs lgctrcy fir rh. Frrbnnnncc ofrhe work lor which this p.rnrir i\
<br />hsrEdlscc 1097. Civ C.)
<br />trnJ.i, N.rnc:
<br />-
<br />Irnd.r's AdJrcas
<br />-
<br />AITLIgANLI}EI;IABAIION
<br />I tmjry aBim under lcnalry otp.ruty orc ofrhc fo,louin8 dccl&rio.r
<br />Dr.bliriDtr Pcnnih'Asbcsx,s N.iiri.n'ion F.dcrul Reguhrions l lnle 40. Pd6)
<br />Rcqu,rcd t rrcrof Nnrifi.dri,n
<br />I .crrilyllnr rhc fcdcralrcBUlirion\ rcEadirg rshc{o\ rc'n.vrlrt nur l1]Dli.rhl. b rln\ r()r..1
<br />I ccnrlylh l halc rcldl[is i, drd stdc rhd rhc $orc irlonndn rs.oftccr t r8rcc l(i.otrglysrhrllCilyrnd Cotrnry
<br />odmri.cs ind Srdc trws r.hcrcbyaurhrir. repr.scnl.rivcs oarhh Ci'y and Countylo cnlcr !Ix,n rrE
<br />rb.!. trrnr(nr.tl p'ot,. l
<br />I L4-9 -C ^(8
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />Rool Sheathino
<br />Shear Wall
<br />Framino
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lr/lasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flgpd Zonq Certif
<br />Poo\)4.,^4 h+7191ff ,{,/ttQlio )rt
<br />FINAL wt\/,6 )J15\
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc
<br />t -k-ta._
<br />Ou {rQ t
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