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BUILDING. INSPECTOR HECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER AUILDER DI'LCARATION
<br />I htrcby lffifln und.r pcnallt ol p.rjury rhd I un.r.n/ arom th. C.nra.k,F Liccn{ L,w ror rh.louowin8 rcasn {Scc70JL5
<br />Businc$ lnd Profc$ion Codc): Atry Cit, or County which r.quircs n Frnrit ro onslruc|. alrcr. nnpovc. dcmlhh or BI{t nny
<br />eo.turc. prinb irs issra.cr,,ho rcqnncsrhc lppliclnr for such pcmir ro file a stmd {8rctunr rharhcorsh. b liccnsd rxr$rnr
<br />ro lhc nmlhions of rlE Conlr..lols Liccnsrd &w (Chaflcr 9. Commcncins wilh Secrio. ?000 of tivisin I ofrhe Blsirus and
<br />Piofcs onsCod.loithr h.orshc hcftmrl rbcrcfroo and rhc Msh for rhc iucecd cx.rption Anlvtrrlio.oiSc.tiotr?0ll.5byrny
<br />amlicurr lnr a pcrmil subjsls lhc rpplicunl lo{.ivilpcnallyolnol nnnclhrtr irc hundrcd dollus(55UJ).
<br />Zl. $ os Rr or rhc pmFd r. or nly c illloyt{\ w h s re.s as lh.i, v,lc .omp.nsrtion. *ill do rl* eork and rhc slnrlure h mr
<br />inlc cd oro0crcd for $lc (SE 7041. gusimsand Pmfcsions Codc'rhc ft' mctoi s Liccns Lnw doc\ nor annly ro an owmr ot
<br />rh. ,,oFdy who hoildr or iftpows rltm,n, md wh d6 sch s('A hinsclfor hcRlf or rhtuughhi\ or h.r o*n cmploycca.
<br />pri,vidcn rhd s ch in{,rcknrnrs N mr iorcnd.t o, .ficd f.r slc lt h'wcvcr rhe hildin8 or iqreem is $kl wirhin nc ,tu
<br />olcorrtrion- lh. O*mr Bril,ls ll hoE ltE hunhn of tmvirB rhd hc or stu dil '[l blih or in[n'vc lhc pmFny lor thc purrnE of
<br />I. rr osi$ol rh. rrorun), cx.lu\i\clr.ornri'rgwirhli.ctr\crlcoikrrr\b.on{tu.rrlrtx'lc.r(Sc.7(l1-r.lnntrrcs\
<br />drl h.l!$ir Codc lh.Cotrficktrsl.i.cDs.t.dsdocsD.rrt,tlylortrowncr.lfroncrryuhohuiksorimrnve\rhcrcon.
<br />r d who rontrd\ rr su.h Frticcrsqirhr Annmck,(n li.ctr\cd nunuJnr k, rhc ContNt, \ l-icr \c hw).
<br />,7 /z
<br />DICLAf,AIIA!
<br />I hcrcby rfttn undcr rcnrhy oi !.rjury oft orrhc rollowirg dclarariotrs:
<br />L'lnr c, c. lnrr[c pcrlorno.cof'hc qork hr *hichlhc,,cnn]r n ls{'.d
<br />Ilrvcrndwill rinrdi'i wortcra.onfcn\ ion insu0ncc. r\ rcqutc hrSccri{{ lT0Oofthc lit\tr Codc, (rlh. Frlirnno.col
<br />rhc work lir which rhis p.nnir i\ issrdl My qorkcr' emp.isrbi nrunnrc.rftrr *kl I'nlrynunrbcrdc:
<br />Poh.yNu rtr Erti
<br />-l.cniiyrhnl
<br />in rh.pcrfonninccofihc w.rk Inr whichthis p.flnil i\ issrcd.l shnll..l c.{,kJyany ncrs.n ir anynrDNr
<br />$ ns k, btconr subjccr t, rhc wrr[LJr coDFnrllion laws oi Crli6rni0. drlrcc rh8r il! \hould hc(nrc sutjcd r.df,
<br />w.rkcrs co rp:nvri.n F,vi\ins of Sccr ion ]700 of rhc bh(, Codc, I \h3ll. fonh*irh co'rply r irh rhrr pmliiionr.
<br />WARNINC: tiilurc b corc wo cs .onrFnsaron covc.rg. i( utrliqtul. i.d shrll suhic{r an emtloyn lo aimiDllpculrics ond
<br />ciril ftrcs uD ro om hundrcd rhousnnd dollrs (Sl(x).tlfi)). ir rddiriur ro rhe cosr ot compcnrllion. danuscs !s pfl,vidcd for rhc
<br />SNrion 1076 nlrhc Ltbor CCc. inrcrc{ md hrmy ( ie\";;:." -." " ; EI' ;',"-
<br />";;: ;: F/-,!l![Ntul( -tx,\(loBDILLr$IIQ!
<br />I hcrcl,y rfirnrundcr pcnllryolreriury lh r rm liccnr{ undcr nmvhiotr ol Ch.plcr 9 (commnc in! wirh Sdion ?fiD) ot Divki{,n .r
<br />oi rhc,:lusincs ond Profc$ionsCodc. !M nry li.ctrsc i\ in lull foruc dcfltcl
<br />gNsralcuoNt[NrtNlilcrN(.I
<br />Ihcrcnyrriir utrdcrlfnrllyoipcrjuryrhnrthcrchr.on{dcrhnlcndir!,gctrcyforItupcrri,r. n.. olrhcwork forwhichrhn pcnnn is
<br />i$xcd (sc...1097. Civ. C ).
<br />I.ndcar A{rdrssr
<br />-
<br />ATIUqIILDI;ILA8AIII}N
<br />I trthy rnnnotuicr pcdrlr, oftujurt.Dc ol rh. follotring dc.hfiri{nN
<br />Ircdniion l'.nnit Asbcno\ Noriricrri,)n licicril Rcguhrion\ r lillc,1lr llr$)
<br />It.qui,.(l l.rr.r,'iNolili.rrior
<br />-l
<br />ccnirylhlr rhc fcdcralrquhlions rcArdins a\hcsios rcnn,vilr. tror rt'di..hlc ro ihir p(xcr
<br />4lr::llrr lh$. r.rd rlris rI/lrJri,,,rRt \rrrc rhrr rhcrh,r. i',ri,nnrri,tr, n.orfri l3!r.r
<br />con(rucriotr. iftt hcrchr rurkriTc mprc\cnrrrivc\ o
<br />atnnr Eoliorcd toFny ld ins!..I
<br />Appli.mt or /\S.DI Sigmlum:)(
<br />e"-i,* nrnr" tp.inO;,K Pl+'f iJa )
<br />tu condy *irh all cnyand connry':^'.';"';1"7;-
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />Subf loor/VenVlnsulation
<br />Rool Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulationi Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlAsonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Beport
<br />En Final Reportgrneer
<br />Flood Zone Ceftif
<br />'....-.\
<br />FINAL t(t*tt6m >V\ttil->2-/
<br />Certif icate ol Occu n
<br />Notes , Remarks, Etc
<br />-+
<br />Forms/Steel/Holdowns
<br />SLAB Floor
<br />I]
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