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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATIoN
<br />I hcrchy dlltrn urnlcr Fntrlry of Frlury 'har
<br />Ln cxcn1pr fs,n rh. c.nak(d Licn{ taw ft,
<br />'hc
<br />lollosirg rclgnr (Scc 7011 5
<br />Bt\ine* lnd Piofcsiotr Codc)r Any Cily or Counly whkh rcauircs ! pcirnn ro connrucl. rl'c!. improvc. dc'mlhh or rcn n .ry
<br />{turrur., rirlo irs nsuoicc. lho rcqutcs rhc arpli(l.'I lorsuch Irrmir n' filca si8ncd srarcnEnr rh hcor sh. i( Iiccnscd l)Ursarr
<br />ro rhc pmvGions ol rhc Conr@rois Liccnscd tiw lCnnpt.r 9, Connrcncir8 wilh Scction 70u) oi Divniotr :l ot rhc Bu\inc$ und
<br />Pmrcsnrns C.Ju) or rhar hcor\hc ncr.frpr rh.rcamnr alld r hc hr\t for rhc allcgcd ci.nfln,n iyvn)hrbnofS(ri.n70:tl5byany
<br />apllicrnl for. pcrnil subjcch thc applicinl
<br />'o
<br />acivilpc.rhyoriorfl)rrhdn tirc hxndrcd dolldrsl$500)
<br />l, ,\ .wicr of rhc lrolltny, or 6, cmnloycc( snh wr8cs !s lncn {nc co rFnsllt,r. uill do lhc sork md rhc {turut i. ,k
<br />intcntlL{ or offcr.d lo. slc lso 7o1-{. Bu\ircs rnd Pn'L\sn,ns cdl.: 1 hc Grrra.rtr\ Li.dnsc hw der mt rnDly ro in .qIcr .l
<br />rhc nn)Fny who hilds or i',rr(^rs rh.R,n. a'i $h) dms sMh {orl hifl\clfor h.r*lfo' rhroueh his or hfi oen.mployccs.
<br />rrovidcd rhor such imprevcflrtrt! {c tror ir crdcn o o ar.d rn src. l( h'ucvcr, rl.c huild ill3 or in{n ovcnrnl i\ $ll $irhin t rr r,r
<br />oi.onlplcrkn. rhc Owkr Brild$ *illhM rhc huilcnofpn,vnl3 rhr hr or \hc d i.r huikl o' in{n,k lhc !trrtdy br tu purJbs of
<br />_l- 0sowncr ofrhc pn,lEny. rmcxcl'Rivelycotrirrcrin! wnh licc$cd conrmcnns rn cotrnrud rhc Frccr (Scc. ?(}!. Busnc$
<br />dii Pturs\bi Qd.: Thc Cdnt&tor's Lirc.sc Law doc\ nor spply ro nn ownrr of pn,rc rwh() hrildsor inrpocs thcrcon.
<br />and q,ho conrnrls lbr such trclec wilh a Co n rons) lrcn{d !u uinr ro lhc Q)fltrrcror's Liccnsc ljw).
<br />I. nc\crnN trrJcr Sc. tr1' .B A P('1{rhtr'rrlnr\, A-=-f 6tmcv L \ l arI ' llatrE8s:Llr!.lfuNr.lJtea
<br />I DECLARAT(IN
<br />I h.rcly.'ll.''nd Jcr Fr'lr) .,1 Frjury., r'.I'h. n,ll',tr:nr J,,ltrr!'.\
<br />-ltoveardwillnuinrainrCcniaEarcolConscnrroScltltrurclturo
<br />(c6 compcnsarion- as l]rolidcd for hy sr.rioo.rT(x) orrhc
<br />L0&, Gidc. for Ihc l)crfonnamc oi llE wo forw[ichrhrpcnnirir nsucd.
<br />_lhircan'l sillm!in'oi. rorkcr'conrp.n$rion insurucc, ar rcquircd 6y Sccrn,tr l70O ol rn€ b$or Conc. tur rhc pcrrormncc or
<br />olrier unn Fnicy nunrhcr urc:hrhis pcnnil i\ hsud My
<br />,,,,,,*, OJCS ((-l-l /
<br />I c.diry rhar in rhr perrortuncd ofrn. *ork f(tr which rhis oermir i\ issucd. I shrll nor c'nploydy p.ron in rny nB.ncr
<br />s trs to tEonE subiil ro rhc worlc^'comp.ns,riLnr hws or c,lihnria. hl |8rclhal ilI should tEonE suhJal rorlr
<br />lolicB.rmprtrs0lionpmvhiors.lSccrionlT(DofrhcL,borCodc.lsh,ll-l'odhwirhcoq,ly*ilhlto*provisn,nr
<br />WARNTNG: Frilurc ro surc workc( cotrlxnsrbi ..v.asc il xrl0wrul, rnd shdll srh.,c.t rn cnrlloycr ro dnninil Fnalries and
<br />civil 6trcs ut' t' otrc hu6dr.d rhousrnd dolhs ($1m.000). in rddiri. t' rhc.o( or.onr!.ns,ri'nr. damiges is nrovidcd for rhc
<br />Sccridr 1076 of rh- tjbo. Qxlc, inrcrsr and anormy r fcds
<br />8-s -t & pili.lnii
<br />LIEINSIILEONIAACIABD!!]r'l&llqN
<br />I hcrcby,rfirm undcr rcnahrofpe.jlryrhor Ln liccnsn undcr nnvision olChanrer9 (conrmmins wirh Sccrk,i 7000) orDieisioi l
<br />of lhc ltusinc$ nDd PrcicssbnsCodc. o myliccnsc is inInllr(,rcu clfcct.
<br />cY@ 7
<br />7 Ol-
<br />grluBt&rtaN.LrNDtll;-dlirlrI
<br />Ihctuhtrllirrund.rFnahyofp.rjuryrhrrrhocn,(tr{tucri,,rkidinga!.n.yforrhcl.ifoi'run.cofrhcwrkntr*hichrhnNnnitis
<br />is\ucd(s( lrll)7_ci c )
<br />Lndcis Addrcs:
<br />-
<br />I(.,rrlvrhxl rlI1.,1.'x rrg ]rnnN,rgrlltr!i\lr{o\ rc ktrrlJo trfr x
<br />-l.cniD
<br />rhir I hNr ic rhtnpflicnlio d is conccl I rsrcc bconrd, wilI nllCirr rtril CoDniy
<br />odinarcc\ itrd Srarc l-rusrcl,rin-s ro flrrivcs ofrhi\ Ciry and C.unryt) cnrcr uI'{r rhc
<br />nlxr. rnrirnrl pni,irn!lar i'l
<br />,\pplirnDl,tr ,\srnt Sixtr l
<br />)
<br />^,.,t&f-
<br />Formsi Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Sublloor/Vent/l nsu lation
<br />Rpof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulalion/Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handica p Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL lfr.Altx ar'qd
<br />Certit icate of Occupancy
<br />Notes Remarks Etc.
<br />I
<br />Set Backs
<br />UFER Ground
<br />r"
<br />-1 tt
<br />Gnd.a' Nsm:-
<br />AETLICANLI]ECI.AMIIAN
<br />I hcrc.l', ulnm undcr !.nulty ofpcrjury onc oflhc lollowin8 dccl4trrions:
<br />Dcnrcliriotr Pe nih-AstEslos Notification ftdcml Rc8ulario0s (Tirl.40. PM6)
<br />-Rcquted
<br />Lcllcr of Norifi cnlion
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