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BUILDING. INSPECTOR RECORD
<br />DATE ID/SIG.
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFEB Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsu lation
<br />Roof Sheathing fl)r/E'r1 D)
<br />Shear Wall tl t
<br />Framinq
<br />lnsu lation/Energy
<br />Drywall
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />-l l
<br />FINAL I 'frLY/tP ryltzilt -/!*)
<br />Certif icate ol Occupancy - tt -
<br />Notes, Remarks, Etc
<br />OWNER ItUII,DER DELCARATION
<br />I hcrcby ri,lrfl uMm !c.,lry of pcrjury rhll I om cxcn[r from rhc G,nrrs.k,a l-i..ns. tjw ror lnc followins{]soi (s-.'?0.115
<br />ausnE$ d Proltssion Conc) Any Ciry or Colmy which .cquircs , Frmil to con(rucr. allcr. imlrovc. dcnsli\h or En,n dry
<br />srrudurc. pritrto ir\ is\ramc, dl$ oquncsrh. amlicMr for such Fernril lo filc ! sismd rraremnr ihst lror shc is licctrki Puruanl
<br />lo thc provkiotrs of lhc Co.lruclofs Licctrscd ti* (Chaprer 9. G,mn.tuln! with Sc.lioo 7O(J0 ol Dilisn,n I orrh. sunnc$ 0nd
<br />Pdtssions Codc) or rhar h.orshe is.xcmpr rh.Erion Md rh. basis lor lnc ollcscd ercmpln,n Any vn'hrionolSc.tion?031.5 hyony
<br />amlicanr fd r Frfrir snhjda rhe 0mliunl lo a .iv il trctr.ll y oI mr m,rc lhui ivc hutulrud doll.ts (S5m).
<br />-1.
<br />{s o*mr otrhc pmp.ny. (r n1y cutl.'yes wnh wr8cs as th.n mb comnen$rion, willdd rhc work od dE \lMrurc is Bn
<br />inrcnd orof.rcd for slc (Se 7044. Busiocs and t\ofe$ions Codc Thc Conrrc(tr s Li.cnsc tiq &rcs nol lPply t' an osn.rof
<br />rhc tmpcny $ho blilds or itr{,ohs rh.K,n.0rkt Flar d€s such k)rt hinNlf or hcrullor rhr.ngh hh or hn o*n cnq,lorrc\.
<br />,)i.vidcd th3rsuch irymvcaBh rc n inrcnd.d .r.[cr.d i{, vL ll, hoscrtr. rh. t uiklin3 or iq)r,vcmnr i\ $!d qirhir otrc r.r
<br />or.. Dhri(tri. r]f Owncr Bnildn will lDrc lh. hurdcn ol pnNing rhll hc or shc did tror bxild or inp.ovc thc pmlEly fin rrt purlr,s .r
<br />L rsowncrorrhc pmicny. anexc[snclyconlra.rins wnh liccnscd.ontr,.rns ro..trsru.r lhc Pr+.r (Scc 7(x.1. Bulift\\
<br />lnd &trii:shn Codc: Thc C.nt(ttr s Lircn\c Lrwdtcs n.r rptlyro rrosncrofrolc ywh. buildsor iDProvcr rhcrcon,
<br />nnd who conrn.rs lor such prcj$ts wirha Conlrr.r{,(n licci\cJ rursudr k,rhcG)ntmdois Liccnsc l-ow)
<br />Irn,crc ,tr tr dcr Sccrtri
<br />Ddl.: opne.:
<br />wrtlxtns' ctlttr.Pns,rrtrtl
<br />IIEC]JAAIIO
<br />I lr'chy arfinn utrdcr pctrrlryoipcrjury onc oirhe iollo*ins dcclarari{,n\:
<br />I hrrcddvillnEimair rCcnificrlcofConsenll{' Sclf lnsurc lor sork$r .onrpcnsrion. us providcd forbySccrtDlTfirolthe
<br />Ilhor Code. ro rhc pcrfonM.c orrhc "or* lor which
<br />'hc
<br />pcirtrit h tsucd
<br />I hrv. aid sill.rir rin sorkcrl conDcnsalion nNurancc. as rcquircd hySc.iion 1700oilhc L!ho. Code. fitrrhc Nrfonnmcc of
<br />rhc w.rk ror which rhis pcrmir is hsucrl. My*o!ks( omFnsarn,i inluraic..ricr onBnky.unrh. uc:
<br />Policy Numh.r
<br />-Expircs:
<br />-l
<br />.cnilr rhar in rhc pcrtuntun.c.frhc work for which rhis lcirnir is issucd. I shrll tror.nlFby iny pcson in any rrnncr
<br />v, a\ b bc.. f, suhJer lo r hc wo*cn'compcnsal ion hws ol C.linrnd ,nd +rcc ihat il I should h..om $hjcd ro rhc
<br />workc6' strrttrtrsrrion provkions oiScdion.l )ofrhc I rhtr (',nll.I shr]. tullr h.oolflyxihrln{frrnrtrA
<br />$.\R\l)i(; r rtrrr r) {!trr! {f,Lr,\ !o $t n.ovcru8c is trnlu$iul. Jtrd \hrll {,hJc.r .n ctnPloycr ro rintinrl Ftuhi.\ md
<br />(Slm.om). ir lldirion k) rhc co{ ol..oncnsarnr. d.m(8cs r\ ni(*ilcd fd rhcrn I ln,c\ ut k, oN hundrr ihousrid do
<br />sd(1irtrr.ro?a or1h.llhtr( rtrlc. i, crcnr "R.^en-q 4,""t7 -q *1
<br />I tct,tNsft) ({)\ tR.\( llI{
<br />I hcrbydm n uDncr pcNlly oipcrju rl,rrID,li!.wlutrd.'pr)vi\mfol(luIr.rg(.onn,rnrir!{[hSc.in$7(xxJroil)ririr.]
<br />ur rho Busirr$ rnd Pmfc$ionsCodc. un nrylncok h in fullnn.. dxl clrc.r
<br />too 73,-t9
<br />I lx-rht nllirn unls Fnrlryol pcrjury I
<br />n\ucd (Sc. :1097,Civ. C )
<br />Ltrdins .FcNy lor thc pcrfortuftc ol Ihc Pork io! uhich rht Fmir i\
<br />AIILTCANLDICLA8A:IIAN
<br />I tmby altif,n undcr I'cnall y of p.rrnry onc ot rh. f.lb*ing d.tl.r{l ionsl
<br />D.mniion Pcrnn$Asbcstos Noriliclrion FcdcEl R.golnri)ns (l'i'lc 40. Puni)
<br />Rcquncd Lcllcr oi Norifidion
<br />rlc nor {tli.ablc ro rhk prcirt
<br />li)rrulion i corccl t asrcc ro .onlny wnh lCilylndOnrly
<br />y aurh.rizc rcprcscnlarivcs ofrhi\ Ciry and Conntyto cnler ulnn rhc
<br />,,",.8-1:t4
<br />SITE-WORK COMMENTS
<br />I
<br />Ext./lnt. Lath
<br />o,,"8 -q -,trt
<br />trnJ.i\ Addrc$: _
<br />I
<br />0-t4W1 E
<br />F---f--
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