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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS O1VNER BUIT,DER DELCARATION
<br />I hcrcby ,mrn undcr pcnally ol pcriury rhdr I m cx.npr rtun rh. Conka.h^' Li:cnsc bw aor lhc followin8 aren (S$ ?0.11 5
<br />Busincs rnd Prolc$io,r Codc): Any Cily or counlt whi.h rlnutcs 0 ttrnil to con(rud, 6hcr. impmve. dcfrni\h nr frIl3t uny
<br />srructurc, prid ro irs L$uaNe. rko rcquncs thc 8fl,licrnr ltr su.h Frnir ro filc! siErEd nlrcorcnr rhar hcoi shc i\ liccn{,1 nuduanr
<br />Io ihc povisnnN of lhc Conlrs.rols Lrccn*d Low lch.prcr 9. Conncrcing wirh Scci,or 7(r0O ol Division I ot rhc Bun;sr rJ
<br />Prcrisrions Codc) or rhar hc or she is cx.6pr rllcrcfioto and rhc hasis tn rhc ill.gcd ermlJ)rnnr. Any vn,htiotrofSR_tion70ll.5 hy any
<br />0mli.anliorrpcrnrilsubjcclsthcaptlicanlloocivilpcnolryofnormor.rhlnfivchundrcddolla6($5ff,)
<br />_1. r\ .wocrofrhcptr)Fny,{trfrrDrployccs wirhslSrsrs rhcir{rcdnnpcn\di,)n, willdo rhc work dxl lh. (raur is nur
<br />inrcnd.ri o, oficr.d fr *L lS( 70'14, Busincsl rnd Pmr.lsn'ns Codr: Thc (tnrrchis Ltcnsc lj* d@s nor "rply b rn owncrol
<br />rhc ptuFny *ho ${ilds or imp()vcs rhjd)n. Md who d*s su.h work hi'ns.lfor hcscllor thmu8h his or hcr oan cmpl.yccs,
<br />pmvidcn rhar such inrpm$mnr\ m fr, irrcd.d or oflcEn tor slc tt ho$?rE, rhc bui[ing or nnpmE rnr Ls $B wnhi. o.c ]u
<br />of c.ryklion, fic owmr Buildn will hn\r lhl bnftt n of pmving lrur h. or shc dn nol build o. nnpro\r lhc ImIEny for rhc !!qrs ol
<br />-1.rowmrolthcrrorcny.rnrcxclusirclyco
<br />riclin8wiihlrcnscdconracroFlocon(rucrrhcpmicllsec ?O'r4. Bu\i.rs
<br />mdPDfcsi,nCodctheConrracn,sLi.cn\el,owdocsoorupplyt,mownerorni{,td,shobuildsorinl)rovcs'hcrcon.
<br />rnd wh. o.rids for such prcj$h {nn ! Conhcb(, li.cnscd nusud to rhe at)ntactois Liccnse L!w)
<br />-l
<br />!mcxcnrrr und.i scctio J1R-
<br />I hc.cby lffi n undcr lrn,hrofrcrjuryonc ofrhc iollowing d..lmri(rs:
<br />-l
<br />havc ud wrll ruinlai. a Ccn itcarc of Constrr 1o Sclllnsurc f{, workcn' ompcnsnrn,n, $ provid.d for bt sc.rio..l70Oofrlrc
<br />L{bor Codc. lor lh. Ir.doirMNc oi thc wolk rbr whicn lhc pciinir ir hsucd
<br />rh. {r f{tr{hi.h rhn pcnnir i! Gsud lllvsItr[.^.on,!.nvrioni'rurrmc.rricrxndFlirydun$rr$c
<br />Policy Numb.r
<br />-Erpircs:
<br />l.cnlfyrhd rhc p.nnntuNc.frh. sork n, shi.h rhN !.rnir i{ 6sucd.Ithrllnor cDDby ony pcnon in rny nrnncr
<br />s !slohccorE suhjccr t,lhc sorkcrlconrrEns ion hssofculifonrir onJ asrcc rhar irl rhould h..ort \ubic.rrorhc
<br />wortc con,Fnsationpn,vision\.rSrcrn,nlTlX)otrhrLJhtrCodc.l\hall,tunhwirh.o ply wirh rho* !m\ hi.ns
<br />$ARNINC: I'lrlurc lo sccur! sorlicn compcnsrrion coErrgc rs unhstul. rnd \hrll subjc.r rrr c'ryhy.r k) ditrrirtrl NnullEs 0n
<br />civil lincs !p ro onc hudlcd rhorsrnd doll$ lsll)O-(xl)). in andiion h rhc c.n orco'npcn\nrtui. d, rrlcr .s lrovnbd lor rhc
<br />J@/-,/4Appli@nl
<br />DEgI,AIAIION
<br />I h.mby rf6rmund.r pcmltyofpc.jurt rhd I an lic.ns\] undd Iovkion ofChrpts 9 (comnErcinE *ith Sccrbn 7(r0) orDivknrn l
<br />of rhc Busii.$and Pretc$ionsC.dc, ul my lt.osc n in tu ll t6,ft dJrl .flir'.
<br />Li.cnsc Numbcrl
<br />IONSIBIICUONIDNPBIiIIiENII
<br />I lrcmby altuh undcr r.mltyofpcrjulylhal lhcre is a con(oclion kndins nscncy ntr rhc p.nnntuncc orrhc work for whrh lhis rcmir is
<br />Nsucd (Sc.. 1097. Civ. C,
<br />APPI ICAN-T DTCLARATION
<br />I h.r.by dflimr u Mcr p.n.lry ol ,crjry om of rhc followinS dcclarit ions:
<br />Dcmolirio. Pfioirs Asbcdo\ N.rin.arion Fcd.nlRceulnrio l(Tnlc 40. Pdrl6)
<br />R.quncd tl(.r ol Nrili.dion
<br />-l
<br />ccrrilydrat rhc iedcrnl rc8uhln'ns rsudin8 ashcsro\ rcnDv rc mr aprlicnblc t,rhi pr&cr
<br />l.cnilrrhxrl luv. rcrd rhisdt,fli.rridra,xl{drcth lhc nhrr irf(r.rridr is ..r r.cr I l8re lo @nrly wirh rl1 Cny lnd Co!trrt
<br />odirrn.cs nnd Std. bws rclrtrA in8 conslrucron. &ld h.r.by aurhorizc rcprcsnhrncs otthn Ciry!.d Coxnry b.nr.r uB,n rh.
<br />ah)vc
<br />'mnr
<br />i{nrcd roprny aor 7-<?bA"z -t9
<br />Set Backs
<br />Formsi Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Sublloor/VenVl nsulation
<br />Roof Sheathin g
<br />Shear Wall
<br />Framing
<br />lnsulationi Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lt/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />I
<br />FINAL h\\'r \r1 Ultht^
<br />Certificate ol Occu pancy
<br />Noles,.Bemarks, Etc
<br />(oo(
<br />1 L.
<br />^
<br />(r
<br />Cutr
<br />Sc.rin.lo?6ofrlrc l!hn (inlc- inrcrrn rDd rnon'cy s li.\akq
<br />Ll'd.' .
<br />^l,Ics
<br />Appliont or Agcnt SiAtr.lun:
<br />UFER Ground
<br />O oart &
<br />v'r{a\t\ /
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