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SITE.WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loori Venti lnsulation
<br />Roof Sheathinq l-4 tB JL,S6{1 4r
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL ?d{,4x 5h<q
<br />Certificate ol Occupancy
<br />Notes, Remarks, Etc.
<br />EUILDING- INSPECTOR RECORD
<br />olv\IaR tI LDl,k llll.{ /\RA l lo\
<br />I hcrcby lfljr un.lcr pcmlry,,r pcrjury rhal I on qcq,r rron rhc conkrlo^ l-i.ctrt bw lor rhc adlowin8 rcren (
<br />Br\i'rcss md Pbrcsion Codc): Any ciry or counry Bhich r.rluims d Frmir lo .on(rucr. ahcr. iq)roE. d.d)liih or ic!'!t anv
<br />srructurc. priorlo ils nsuan.c,.lso cquircs thc apPliclor i(, such IErn ro 6le ! s,sn d nlrcmnl rhulh.or shc n liccnsd pumatrt
<br />lo rhe fl,visi{,nr ol t}. Conrruclois Li..n$d kw (ChaPrct 9. Conlncnci,8 qnh Scdi.n 7000 of Divhion :l ol d' Burinc\s dnd
<br />Ptur.ssi,ons codc) or rhll hc or sh. G .rcnri lhcrciro,n and rn r,asn rdr rhc allcBcd cr.mprhn. Anvliolarion.lssliotrT0ll56vaiv
<br />lppliconr lor 6 Fn ir cubjc6 rhc applicanr ro a .ivil Fn,lry ol ot mrc rnsn rivc hundrcd dolhB ($5m).
<br />I. 0s ovncr of rhc pmFny, or my cmploles *irh *agcs ,s rh.n sb conrF.\ar ion. will d. thc sorl aild rhc slEr@ ir mr
<br />inrend.d or oftercd for slc ( SN.7044. Businc$ n d Prcfcssions Codc: Th. Contt.cxr\ Licn$ trw dEs tror q,ply ro i. ownci 'f
<br />rhc D$scny who huilG or iqxJEs rtEmn. ffil who dffs such w,rk hnnsclt or hcntll or rhmu8h hh ot hcr o{n cq)lorccs,
<br />Irovidd rhdr such inDmvenEnk d nor intcndcd o! oltarcd fo. slc li howcw. rhc huildi.g or nrgrov.mnr is sH wirhin om vlar
<br />;l con{,lcri,tr rtr owncr Builds will hnw rh. burdcn ol [ovins lh,r lE or \h. dil mt huik or iiPmh ln. lmFnv ror rhc l]ltpos ol
<br />l. $ owncr .l lhc F)pcd y, dD cxclFivcly contmr inE wirh l(.n\cd cotrtlcttr\ t, .o nrud lhc Pmjccr (ss. 7olt. Bu\iru'i
<br />i'xl Pl.ll\\inr Codc IhcConrracrois Li..trscL.wdrcs nor lnrlyk, rioRner olFoP.ny*ho buildsor impovcs rhcrNn.
<br />rnd sho conroc( r(, su.h prcFt\ wirh a C.nrm.ror{s ) lNnscd Pursulnr t, rhc Conkrlois Liccn{ Law).
<br />I imcxcnrpr undcr Sc.rn)
<br />Dole: OMer
<br />wonxrrsi r:otlrprrri,rrroN
<br />DECLAIIIIO!
<br />I hcrcby rl'lirn undcr pcmlryorpsjuryoncoflhc rink,wirs dslnt,rions:
<br />-l
<br />h{vD sn will nDi.rain . Ccniicolc olConsc b sclr-ln$trc lbr *orlcr'..m,1!N n'n.us P(,vid.dforbvScclir)n.17(x)ollhc
<br />tibor a*lc. for lhc orrforro'rt of rhc work i, *lich rhc pdnir is ssuci.
<br />-l
<br />hrvc rnd will nmi iin *orkcF conl]cNrrion insuratrcc. us r.quircd by Scd ion ]Ton ol rhc Ubor Odc. for rhc !,ofortuncc of
<br />rhe &rk for whi.h rhis pcrmii is is$cd Myworkm ompcnsarion insur.Nc cari.! $xl roli.v flumbct !rc:
<br />Poli.vNunrbcr
<br />-
<br />-l
<br />c.nify thd hrhc pcrlir.rEmc of rhc work lor whichrhh Pcreir i\
<br />^sucd.l
<br />n[U nor cnfloyonvpe^on inmvnunncr
<br />b aslo hccom subjcct ro ihc workcn' comP€nsarion LwlorCtrlirorni!. and rgm lh{r iil should bec.nx subj$l loric
<br />vo*6s conrrEnsarionprovhionsofSdion:l?0oofrb. Ltrhtr Codc.l shall- rodhwith mn{,lv }nh rbs PDvisions.
<br />WARNINO Failurc ro scurc workeF ..nPcns iotr covcmsc is rnl,qrul. and rhrll suhic.r .nplor. ro diminal FmhiB {M
<br />civil lincs uP rr, oic hundtcd lhousaid dollm ($lm.mo). in addirirnr k'lhe cos otconFnsdion dtrruscs 's !r'vid'd ror rhe
<br />Sc.rn,n l07o ur rhc lihor ('ndc. mrcrcv Jnd Jnom!'\ fc.L
<br />o*", 7-z--1fl o,,,,*,,K € r4-.-1,+/. II(ENSEOIANINAINA
<br />DEIIABAITON
<br />I hcthy trmrn undd pemlry ot pcrj,ry th l am lieninutdct Ptr,vkio. oI Chalrcr 9 (co.mncins wnhSernn Tlr(x))ofDivsn)n 1
<br />ol the Busine$ rnd Prolcsrn r Cod., lnd myliccn* k in tulllhrea .ff.ci.
<br />""",7-2--!8 l,l..<.-L-6
<br />IaNSIBICNANTEIIINA}GIIII
<br />I hcruh, slfinnundcr lcnalryolFrjuryrhd rhcrc is i onsltocrion kndin8 n8cncy tu rhc p.tfonruncc orrht work tor which rhiq Pcnnil n
<br />nsued (sN.1097, civ. c ).
<br />APPLICANT DECI ARATION
<br />I noEby! lmundcr p.n,lly of lcriury Dns orrhc lollo*ing dccloralions:
<br />Dcmlnion Pcrmirs Ast {os Noriication Fedqal R.gul,ri,ns (Tnb40. P!n6)
<br />R.quncd Lcncr of Notifi.orion
<br />-l
<br />cd iry rhar rhc r.dcrul rcallaridns rsJtdina osbcsros rcmrval ft nor lldi.ablc lo rhli Pojccl
<br />IccniSlhallhltrEudrhi!ryPlicarionatdsr,rcrh,lrh.nbovcinioirrulioois.oret.lacxero.oFplvwnhallCirvondCounry
<br />ordintrrccs;d sIalc Llws ehrini io bnildins conshcrio., nd h.rcbysurhn2e dE*ntalivcs orthi\ Cnv md Courvro 'nlc' upon rhc
<br />atDv. mnlbnlt pmr.ny for in\pc.lion purposes.
<br />Appric.nr o. Aaenr s*Nruf il. (c - u'^'- cl*
<br />""" 7- 2 :i g
<br />p.mi,ensme,prinr,: &)4",
<br />Ext./lnt. Lath
<br />I
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