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BUILDING- INSPECTOR FECORD
<br />SITE-WORK DATE ID/SIG,COMMENTS OWNER BUILDBR DELCARATION
<br />I hcrcby ofinnt undcr Fnnhy oi pcrjLtry lhal I 0m crcnfl norn lhc Conrrcror' l,iccnsc l,aN ln! rhc rdlbwirg rcdon lsc..70ll.5
<br />Busirrcs fln Proicsion C.dc)r Any Cily or Counry Nhic[ rcqutcs ! Frmir k, con{ .t. allf. iryrcvc, dcnrlhh or Epat my
<br />srrucrurc. pritr ro irs hsulice- dlv, rc+nes rhcapflicrtrr ior skhttnnirb lil. rligncd n,remnt rhal hcorshc i\ li.cn\cd punuanl
<br />lo thc |Nvkiotrs ollhc Conlractor's Liccnscd t w (Ch,prcr 9. ConnEncins wirh S.crn'. 7(x)o.r Divisi.n I .f rhc Busirrcs rtrd
<br />PmlcsionsCodc)orrhrthcorsh.hcx.n{rrhcrcftofltrnJlhchasislnrlh.allcgcdcxcmplion.AnyviolalionotScclionT0.)l5hynn,
<br />rtplimnr for a pcnn subja* rhc applic.nr lo rcivilFtrrhyofnol nFrcrhan iivc hundrcd d.llars($500)
<br />-l.asowncrofrhcrmpcrry,ornryenrpk,yNsNirhelscs!\rheirs,h.o'nr.is,ri{ri.eilldohcworkudrhcslruclurcisnolinrcnd.d oronircdf.rsrle(Sd.7O{1.Busin.*Mdt'rofcsbnsCddcThcCotrtrclo.sLiccnscL!*docsmiapflyroa0owrcr.f
<br />rhcpmpcny who builds or in{,r.vcs rhcrc,n. nlrho dms such Nd( hiisclfor hcr*lf.r rlmu8h hr or hcroNn e'nployccs.
<br />flovidcd rh.t such irprowmnls e mr inrendcd or oflend for s]c li howekr rhc building Dr inProvdrc n st wirhi'r on. )Br
<br />of onpLrion. rh. Ownf Buitlcr will hrvc rhc burdcn of pii,wrg thar hc or shc did trol ttrild or iryrrt ih. I}n)ldy lor lte pur f.sc oi
<br />-1.
<br />as owncroarhc pmpcny. inr.xclurivcly.onrrriin8 *i(h liccn*d conrrnB r. .otrnnr.[hc tor:cl lScc.7Ot-1. BusiE.r
<br />and hsic$tr rCoJcr ThcCotrt..tofs Liccrsc Lrwdocs nor rDnlyro !n.wncrolpfl)pcnywho buil,l\or inDrorts thctcon.
<br />lnd uho conrrrlslor such prcjcch *nh r A,nta.bnn liccn\cd pu(umr lorhcabntucrors Liccnsc Law).
<br />lorncr.'norundcr Sccrion .8.&PC f!thtrr "i,
<br />UAAtrE85_EITMS'NIATON
<br />D&CI,AEAIIQN
<br />I hc.cby iftnflundcr D.n.lry olpcrjury onc oflhc rbllo$ins declarulions:
<br />I hrvc d willtrnirldn.C.nificatcolCoD$trIro SclflNurc,or workers L1,np.Ndknr, as rolidcdlorbyScclionlTOl)ofrhc
<br />t!b.i C.dc. forrh.r. anndi.c.lth. work for which thc Nr.rir is hsucd
<br />I h.rcand qillm.i .in$o*crs cowctrsntnnr nsurrncc. rs rcqutcd hySocri{n1l7fiJofrhc ljb.r c'odc. tbr rhc Frlornuncc ol
<br />lhcworkr'orwhichrhhpcmtilisissucdMyworkersc.n,ri.nsrlioninsLrlncecarierrtulBnicynuftcrtrc
<br />PolicyN!mbcr:-
<br />I.cnify rh $ rhc |crfonM..c olrhc work tor which thh pcflnit is knrd. I shlll nor cnpby ri, lcnon nr rnt nrtrrcr
<br />y, s to bccoN suhtc.l lo rhc so cr' conr Dcnslr io n liNsolcrliionrir. and rsrce rhnr irl sh,uld b..otrt subiccr ro llrc
<br />work.n'.onrpctrsirionpro!nbnsolSccii{nr:17(x).IlhcL!6orC.dc-lrhall.lnrh(irhcohpl!$ithrltoscPovisions
<br />WARNINC: Failure xr srrc w(rk.* co'nrcns rn,n.a,vcDa. ir unldwful. md shill subicd aI cmploycr h.ri'ni'd n Mlric\ rid
<br />civil fincs up ro onc hundrcd rhodsnnd dolllrs isl(rl,o{XD. in rddnbn b rhc.otl .i c.mpcnsation. dlnnacs Js rr.vid.d for rhc
<br />Sc.(oD 1074of lhcIihtr(inlc inrcrc{nn,lrrtrnncv \fcrrg't'{'tb
<br />DECI,ABAII9II
<br />I hcEby aliirn undcr l..alry ofpcrjury lh l an li.cnsd utrdcr pLovision of Chatlcr 9 (comtuncing wiih Serbn ?uJo) of Dirisiofl l
<br />ol lhc Bu\inc$ and PDfc$ions Codc, and my liccnsc i\ in tull rod,trl.r..r
<br />IANEIB!]CIIQNIENIINCJGINCI
<br />I h.rchy firnridcrpcndlryotpcrjurythn[hcrcisa.otr(rx.riorllcndirpr8cncylorlhcpcrlonmnccolrheworkfnwhi.hlhirp. nir is
<br />nsued (sec 1097. Civ C )
<br />AIIUEANLDECLAA ION
<br />I hcmhy rninn trndcr pcirlry ofpcrlury onc orrhc lnlbwinF dcclrarnr\l
<br />Dcnmliliotr Pcnnils Asbcios Norifi.ari{'n l-idclilllcAUhli{,,\ (l.nh r0- P,(6)
<br />-Rcquirci
<br />L.rlcr o, Norill.ari{)n
<br />l.c ilirh rh Ldcrdlrc8nhlnrtrs r_gednrS asbcslos rctrFvnl c nol.frllcihlc roIhis prcj.cr
<br />l.cnilyrhrrlluvcrcrdrhisrpplicaltnrflaln!terhrrrhcah.r.0n)rn,:iiori\con r IagrNro.. rtrywirhillCiryafdCounry
<br />ordimmcs rnd ShrcL.ws rchrln8 ro huildins n(n,dirr d hcrchy lurhori2c rcflc{dkrn$ ofrhi\ Cilyand Coutrry ro cnter unon rM
<br />rho!r n'.nrnn'rd lrrtr'1! l(r i'Nt(rri,rr
<br />^,"9-l'1'/fi,\ppliu l.r ,\sr.l Sixn lurr
<br />Set Backs
<br />Forms/Steeli Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />ln s u lation/E nerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL 6/eo/ls Arq\
<br />Certilicate of Occupancy
<br />Notes, Remarks , EIC.
<br />l-ctrdc . AJ,[c.,
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