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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILD!iII DELCARATION
<br />I hcr.h,.mrn lndcr lcnllry oI p.i.iuiy rhd I n cxcnrlr from thc Co ncron l -ic.nsc ljw for rhc r'ollowiry rc0$n ( S.t 7O.l l 5
<br />Bu\in.\r xtul Prof.ssion Cdlcl Any Cily or Counly which rcquircs r f.nni r. co.(ruct. olrer. iml,rove. dcnknhh '{ tFn Jny
<br />nru.rurc. prior ro ns issuane- al\o 'cqlnes rhc aprlhanr nlr su.h P.rn lo nb s sicmd <arcnrnr rha' h.or sh. is liccnrd nuruanr
<br />ro rh. prcvisiotrs DfllE Conrractols Liccnscd l,a* (Chrllcr q, conmcr.ilre wirh Scdnnr 71(x) or Dilhion I oflhc InFircs and
<br />l}olrsions (:ode ) or rhar htorsh. (.rcnl,r rh.rclion rnd rhc b.sis lor rhc !llc!.d .knllion Any viohlioooaSerion?0ll5 by ant
<br />aptli.am rffdp.rnl subj.chrh. aptlicanr lo acivilpcnlhyornor nrrcrh llvc hundrcd dollas (55(x))
<br />l. $ oqNroflhc prep.nr-.r nly.'npk,ycN snhw.!.s!slhcir slc c.mpcnsrrion. willdorhcao,ko rhc$Murcivxn
<br />irrc.dcrl or olfer.d li)r sDtu (Se.1(}1.1. Busircs 0n! Pr.ltssions Codc Thc Conkkttr s l-icctr* l-r* docs tror lPPly k, trr owftr oi
<br />rh.ln)pcdy *ho huilds or inpn)ws rh.mn. dxl wlkl dds N(h w)rt hinNcll or hcr*ll or rhmuEh tus or hcr own cmpk,y.cs.
<br />prcvnbd rhrr su.h nnprownFnt 4c not inrcBlcd or onimd lor slc.Il ho$cvc( th. huilJirg or i'nlR*.n*m i\ sld wilhhonc ri.
<br />ol'co Dhrion. rhc Ownd Buikld will hnrc rlE hr $olprcvinglhd hc or shc ilil n.rbuiuor i$rrov.lhc rmlcny fd tlr Pu$)c of
<br />l.isowncrollhcpro,l.ny.!o.rclusivclycont rinp wirh h.cn\cd codricl,trsri,rotrnru.r rlt rolcd lScc 7{)l't. tluim$
<br />lnd thifc\sion Codc: The n,nka(itr\ Li.c scLrwdesnotaptlyhano$icrort)(,t(nlwhohuildsotimPtorcrrhcrcon.
<br />rnd who La,nrtu.h rrtr such pm]-.8 qilh r Co.rra.lo(r) liccnscd nu^urtrr lorhcCo rnd.is Liccnt Lr*)
<br />I rtr,rx.n,t, trndcr Sc.l
<br />","8 :4,1-/6
<br />DECI.A8AIII)!
<br />I hcrcby allto utrdcr En.llyoipcrjury.nc.frhc lnllosinF d(lnralons:
<br />Ih0!candsillnEinllin!Cenificarcofcon*trrbs.ll-lnsurclorsorterscon'p.n\ati.n,r\FovilcdtbrhySccin,n.lT0oofrr
<br />ulxtr(ndc.,drh.pc oflnitrccof lhcBorktuwhichrhcl)cmir i\k\ucd.
<br />I h.vc .n<1 slll .uinhin workcrr conFn\ari( in rntuc,dsrcquircd$ySc.ri(n,.17fi)olrhctrbor(\xlc.f{nrhcpcrlormrr.of
<br />llrc eork lbr whi.h rhis p.lnir is i\su{rl. Myworkcs con[cfsalion in\ur c. carif udr.lty nnnrbcr (c:
<br />Policy Nlmbcr:-Erl,i.cs
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<br />I..niry lh,r i,r rhc !.rionmme olrhc sork tar shi.h ihh Pcnnn h n$cd- I \hrll nor cntloy rny ttnotr in My nrrni.r
<br />s $ lo b.co.rc suhrcd k, rhc uorkc* .o r|En{tiotr l.ss ofcaliri)rnir. rnd rsM rhitr if l shouln bcconr subFcr t, rht
<br />workc^.unpctr\aridrprovisiotrsofSslion.lTU,ollhcLnborC.dc.lshrll,ronhwirhdn.plywirhrh'{fmvaiirs
<br />WARNINC F.ilurc h wurc wo.kcn'.onrpcnsrrion c.vctug. i\ utrl.sful. aul \hall \uhrccr rn cnPlorcr ro sinrinll Fullic\ and
<br />.'!il ri r\ ut h tu hutrdr.l rhouv l dollrr lSl00.l[x
<br />S.(ri,) 10?a rl rhc lnhtr(ixlc. i'n.r.{ rn(lrro,,f,v \ tu.\
<br />con'!. ni( , (tnn A* rlon,vil.,l ntrrhc
<br />I hcrch, aftim hd.r p.nnxyofFrjury thd I !m liens.n ufr,cr povhion .l Chrtler 9 (conmrerciq sirh sc.in,n 7uD) olDivkion 3
<br />of lhc Burine$ snd Eofcsionr G!d.. ,.d my lacnsc is h rull lnre ond cffecr
<br />coNsTRllcl loN r FNntN(; a(;ENcY
<br />I hcrcby.fiirnDtrds lEnolryoipciury rhar rhe.e il a cor{ru.iion kndirS nscrc, n, rhe Frr.rnum. olrhc wotk fo which ihi\ Pcmil i{
<br />ksrcd (Sc. 1097. Civ. C.)
<br />/UILICIINLIIECITIaAIIQ!
<br />I hcEr,y dim xndfi p.n,hy of pcrjury orc ollnc i'olk,s ins delatuiions:
<br />Dcnn)lition Pcr.rirr Ash.so\ Norificntion l€dc.al Rccubrions(lirlc 40, P,n6)
<br />_Rcquirc'l t tcr ol NolilEition
<br />l.cnllirhnr rhc ledcrtrlrcFUhrioDs E!rding rnrno\rc n,rdlrrc Nlrntli.rhI t) rh'\ Phad
<br />-l
<br />cenifyrhrr I h,vcr.adrhisap/tsrioneilstilclhallhcobE innnnuti,,n n.oEccl lrBtrloconulysnh,llCnyundCouly
<br />yrurlatrmrcprcsctrlirncrofrhi\Ciry d Cotrtrry lo cnrcr upotr rlr
<br />ft ovcnE.lioncnp.ot^-n!
<br />Appli.anl or AA€DI SiAm
<br />Pemilenahripri )r
<br />D,t tr-s/ -/8
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsulation
<br />Roof Shealhinq
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lalh
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />Handicap Beq
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL I ,-zE-t0 \)lel*tr Ot
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc.
<br />T-Bar
<br />Dak. g1)l:a &-
<br />^ppti@ntl
<br />Li.cnseClass:-
<br />D.t.:
<br />ZZ Aa.,-,z
<br />-T
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